Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 9735 | TX |
N | 204E00000X | Oral & Maxillofacial Surgeon | E4478 | TX |
NPI | 1245231810 |
---|---|
Provider Name | David George Leibold |
First Address | San Antonio, TX 78229-3901 |
Second Address | San Antonio, TX 78229-3901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 20/07/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
137233610 | MEDICAL DENTAL (01) | TX |
137233611 | (05) | TX |
U49928 | (02) |