Provider Demographics
NPI:1013153592
Name:D. BLAINE LEEDS DBLDDS PA
Entity Type:Organization
Organization Name:D. BLAINE LEEDS DBLDDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:LEEDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-754-3357
Mailing Address - Street 1:1101 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-4420
Mailing Address - Country:US
Mailing Address - Phone:479-754-3357
Mailing Address - Fax:479-754-0167
Practice Address - Street 1:1101 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4420
Practice Address - Country:US
Practice Address - Phone:479-754-3357
Practice Address - Fax:479-754-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR31971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
485722OtherUCCI
AR5T397OtherBLUE CROSS/ BLUE SHIELD
AR136700608Medicaid