Provider Demographics
NPI:1780750810
Name:MCDOUGALL, LESLIE A (DDS)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:MCDOUGALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:MCMANAMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:527 W MARION RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-1257
Mailing Address - Country:US
Mailing Address - Phone:419-949-5007
Mailing Address - Fax:419-464-9355
Practice Address - Street 1:527 W MARION RD
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-1257
Practice Address - Country:US
Practice Address - Phone:419-949-5007
Practice Address - Fax:419-464-9355
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0169161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH46-1296712OtherTAX ID