Provider Demographics
NPI:1952482945
Name:LESLIE, THOMAS WADE (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WADE
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 1:345 CONCORD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411
Mailing Address - Country:US
Mailing Address - Phone:304-258-2291
Mailing Address - Fax:304-258-8188
Practice Address - Street 1:345 CONCORD
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411
Practice Address - Country:US
Practice Address - Phone:304-258-2291
Practice Address - Fax:304-258-8188
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136367000Medicaid