Provider Demographics
NPI:1891351391
Name:LEISHMAN, GRANT (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:LEISHMAN
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 1:139 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1410
Mailing Address - Country:US
Mailing Address - Phone:207-834-3907
Mailing Address - Fax:
Practice Address - Street 1:139 MARKET ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1410
Practice Address - Country:US
Practice Address - Phone:207-834-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN47011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice