Provider Demographics
NPI:1255638631
Name:LEOTIS RICHARDSON III, DDS, P.C.
Entity type:Organization
Organization Name:LEOTIS RICHARDSON III, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEOTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-327-6638
Mailing Address - Street 1:1105 COLLIER DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-8588
Mailing Address - Country:US
Mailing Address - Phone:501-327-6638
Mailing Address - Fax:
Practice Address - Street 1:1105 COLLIER DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-8588
Practice Address - Country:US
Practice Address - Phone:501-327-6638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-19
Last Update Date:2011-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty