Provider Demographics
NPI:1922113554
Name:ERIC S LEITHNER DMD PC
Entity Type:Organization
Organization Name:ERIC S LEITHNER DMD PC
Other - Org Name:WEST GEORGIA FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:V
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-949-1680
Mailing Address - Street 1:8590 BOWDEN STREET
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134
Mailing Address - Country:US
Mailing Address - Phone:770-949-1680
Mailing Address - Fax:770-949-0707
Practice Address - Street 1:8590 BOWDEN STREET
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:770-949-1680
Practice Address - Fax:770-949-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121851223G0001X
GA77041223G0001X
GA67701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty