Provider Demographics
NPI:1295742823
Name:BREWER, LESLIE (DMD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:BREWER
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:PO BOX 759
Mailing Address - Street 2:707 LAUREL ST.
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-0759
Mailing Address - Country:US
Mailing Address - Phone:601-276-9561
Mailing Address - Fax:601-276-9562
Practice Address - Street 1:707 LAUREL STREET
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-0759
Practice Address - Country:US
Practice Address - Phone:601-276-9561
Practice Address - Fax:601-276-9562
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3289-041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01258242Medicaid