Provider Demographics
NPI:1588761373
Name:LESLIE, THEODORE P (DDS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:P
Last Name:LESLIE
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 1:2014 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-8808
Mailing Address - Country:US
Mailing Address - Phone:304-267-4401
Mailing Address - Fax:304-267-0360
Practice Address - Street 1:2014 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8808
Practice Address - Country:US
Practice Address - Phone:304-267-4401
Practice Address - Fax:304-267-0360
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice