Provider Demographics
NPI:1063556587
Name:LEONARD R ODHAM JR DDS PA
Entity type:Organization
Organization Name:LEONARD R ODHAM JR DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ODHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-649-1222
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:FAIR BLUFF
Mailing Address - State:NC
Mailing Address - Zip Code:28439
Mailing Address - Country:US
Mailing Address - Phone:910-649-7222
Mailing Address - Fax:910-649-7113
Practice Address - Street 1:16 POWELL ST
Practice Address - Street 2:
Practice Address - City:FAIR BLUFF
Practice Address - State:NC
Practice Address - Zip Code:28439
Practice Address - Country:US
Practice Address - Phone:910-649-7222
Practice Address - Fax:910-649-7113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996472Medicaid