Provider Demographics
NPI:1649683095
Name:LATHAM, LESLEY NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:NICOLE
Last Name:LATHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6955 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2455
Mailing Address - Country:US
Mailing Address - Phone:510-567-5770
Mailing Address - Fax:
Practice Address - Street 1:2752 GASTON AVE APT 932
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-2736
Practice Address - Country:US
Practice Address - Phone:713-501-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1048481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry