Provider Demographics
NPI:1952662041
Name:ODHAM, LEONARD RUSSELL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:RUSSELL
Last Name:ODHAM
Suffix:JR
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:PO BOX 368
Mailing Address - Street 2:16 POWELL ST.
Mailing Address - City:FAIR BLUFF
Mailing Address - State:NC
Mailing Address - Zip Code:28439-0368
Mailing Address - Country:US
Mailing Address - Phone:910-649-7222
Mailing Address - Fax:910-649-7113
Practice Address - Street 1:16 POWELL ST.
Practice Address - Street 2:
Practice Address - City:FAIR BLUFF
Practice Address - State:NC
Practice Address - Zip Code:28439-0368
Practice Address - Country:US
Practice Address - Phone:910-649-7222
Practice Address - Fax:910-649-7113
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996472Medicaid