Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 7299 | CO |
NPI | 1043454317 |
---|---|
Provider Name | Dr. Laurel Rae Leslie-Martin |
First Address | Longmont, CO 80501-2545 |
Second Address | Longmont, CO 80501-2545 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2009 |
Last Update Date | 29/04/2009 |