Provider Demographics
NPI:1548473929
Name:GOTTLIEB, LEROY M (DDS)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:M
Last Name:GOTTLIEB
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 1:1100 MORSE RD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-6384
Mailing Address - Country:US
Mailing Address - Phone:614-888-2777
Mailing Address - Fax:
Practice Address - Street 1:1100 MORSE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-6384
Practice Address - Country:US
Practice Address - Phone:614-888-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice