Provider Demographics
NPI:1902138738
Name:HAYDT, LEO ALOYSIOUS IV (DMD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:ALOYSIOUS
Last Name:HAYDT
Suffix:IV
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 RENAISSANCE PARK PL
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-2281
Mailing Address - Country:US
Mailing Address - Phone:857-366-1662
Mailing Address - Fax:
Practice Address - Street 1:7252 GB ALFORD HWY
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7661
Practice Address - Country:US
Practice Address - Phone:919-600-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC89111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice