Provider Demographics
NPI:1780889089
Name:LEGG, GEORGE WAYNE
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WAYNE
Last Name:LEGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N 3RD ST STE 4
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6550
Mailing Address - Country:US
Mailing Address - Phone:903-553-0480
Mailing Address - Fax:903-553-0481
Practice Address - Street 1:615 N 3RD ST STE 4
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6550
Practice Address - Country:US
Practice Address - Phone:903-553-0480
Practice Address - Fax:903-553-0481
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6708OtherLICENSE
TX00N357Medicare ID - Type Unspecified