Provider Demographics
NPI:1851480461
Name:LEIGHTY, CHAD ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ROBERT
Last Name:LEIGHTY
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 1:830 N THEATRE RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1700
Mailing Address - Country:US
Mailing Address - Phone:765-664-0028
Mailing Address - Fax:765-673-0488
Practice Address - Street 1:830 N THEATRE RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1700
Practice Address - Country:US
Practice Address - Phone:765-664-0028
Practice Address - Fax:765-673-0488
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124390Medicaid