Provider Demographics
NPI:1831130178
Name:LESLIE, TERENCE T (DDS, RPH)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:T
Last Name:LESLIE
Suffix:
Gender:M
Credentials:DDS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 R.D. MIZE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1808
Mailing Address - Country:US
Mailing Address - Phone:816-373-9110
Mailing Address - Fax:816-373-9120
Practice Address - Street 1:2430 R.D. MIZE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1808
Practice Address - Country:US
Practice Address - Phone:816-373-9110
Practice Address - Fax:816-373-9120
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0147211223G0001X
MO29636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered183500000XPharmacy Service ProvidersPharmacist