Provider Demographics
NPI:1295010742
Name:LEAH BRADY, DDS, PC
Entity type:Organization
Organization Name:LEAH BRADY, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-667-1933
Mailing Address - Street 1:1008 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:701-667-2115
Practice Address - Street 1:1008 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3762
Practice Address - Country:US
Practice Address - Phone:701-667-1933
Practice Address - Fax:701-667-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40018Medicaid