Provider Demographics
NPI:1255561791
Name:LEISHA V. EVERETT,DDS,PC
Entity type:Organization
Organization Name:LEISHA V. EVERETT,DDS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEISHA
Authorized Official - Middle Name:VON
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-376-6565
Mailing Address - Street 1:1100 N MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7201
Mailing Address - Country:US
Mailing Address - Phone:405-376-6565
Mailing Address - Fax:405-376-2443
Practice Address - Street 1:1100 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7201
Practice Address - Country:US
Practice Address - Phone:405-376-6565
Practice Address - Fax:405-376-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty