Provider Demographics
NPI:1942377650
Name:LESLIE, TERRY A (DDS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:LESLIE
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 1:7713 SAND ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-6928
Mailing Address - Country:US
Mailing Address - Phone:817-589-7374
Mailing Address - Fax:817-589-9037
Practice Address - Street 1:7713 SAND ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-6928
Practice Address - Country:US
Practice Address - Phone:817-589-7374
Practice Address - Fax:817-589-9037
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice