Provider Demographics
NPI:1821007469
Name:LEEDS, DANNY BLAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:BLAINE
Last Name:LEEDS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3616
Mailing Address - Country:US
Mailing Address - Phone:479-754-0459
Mailing Address - Fax:
Practice Address - Street 1:414 UNION STREET - 8TH FLOOR
Practice Address - Street 2:SMILE DIRECT CLUB - INSURANCE DEPARTMENT
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37219
Practice Address - Country:US
Practice Address - Phone:800-688-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR485722OtherUCCI
AR136700608Medicaid
AR5T397OtherBC/BS