Provider Demographics
NPI:1831311752
Name:LEAHY, JAN (DMD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:LEAHY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095
Mailing Address - Country:US
Mailing Address - Phone:732-634-7600
Mailing Address - Fax:732-634-7672
Practice Address - Street 1:168 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095
Practice Address - Country:US
Practice Address - Phone:732-634-7600
Practice Address - Fax:732-634-7672
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020093001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice