Provider Demographics
NPI:1104963651
Name:LEAS, MAURRY (DDS)
Entity type:Individual
Prefix:DR
First Name:MAURRY
Middle Name:
Last Name:LEAS
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 1:1818 MARKET STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103
Mailing Address - Country:US
Mailing Address - Phone:215-567-2666
Mailing Address - Fax:
Practice Address - Street 1:1818 MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-3638
Practice Address - Country:US
Practice Address - Phone:215-567-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0179501223G0001X
PADS0356371223G0001X
PADS02736L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223P0300XDental ProvidersDentistPeriodontics