Provider Demographics
NPI:1265559496
Name:WALKER, LEIGH TANYA (DMD)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:TANYA
Last Name:WALKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8486
Mailing Address - Country:US
Mailing Address - Phone:601-790-4374
Mailing Address - Fax:
Practice Address - Street 1:2891 TERRY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-3051
Practice Address - Country:US
Practice Address - Phone:601-371-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3073-98122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1683556OtherUNITED HEALTHCARE