Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | DS017950 | PA |
N | 213EG0000X | General Practice | DS017950 | PA |
N | 1223G0001X | General Practice | DS035637 | PA |
N | 213EG0000X | General Practice | DS035637 | PA |
N | 1223P0300X | Periodontist | DS02736L | PA |
NPI | 1104963651 |
---|---|
Provider Name | Dr. Maurry Leas |
First Address | Philadelphia, PA 19103 |
Second Address | Philadelphia, PA 19103-3638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2007 |
Last Update Date | 08/07/2007 |