Provider Demographics
NPI:1215130042
Name:LEISCH, JARROD CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:JARROD
Middle Name:CHARLES
Last Name:LEISCH
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 1:2047 BALSAM GAP
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-939-0605
Mailing Address - Fax:
Practice Address - Street 1:15137 HWY 110 SOUTH
Practice Address - Street 2:
Practice Address - City:WHITEHOUSE
Practice Address - State:TX
Practice Address - Zip Code:75791-1047
Practice Address - Country:US
Practice Address - Phone:903-617-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice