Provider Demographics
NPI:1750524765
Name:ALFORD, LEROY BERTRAM (DDS)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:BERTRAM
Last Name:ALFORD
Suffix:
Gender:M
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:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0106
Mailing Address - Country:US
Mailing Address - Phone:770-773-7227
Mailing Address - Fax:706-291-0684
Practice Address - Street 1:10 LEGACY WAY
Practice Address - Street 2:SUITE C
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2461
Practice Address - Country:US
Practice Address - Phone:770-773-7227
Practice Address - Fax:706-291-0684
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0088291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00186876BMedicaid