Provider Demographics
NPI:1780958892
Name:DR. LEO A. HAYDT, IV AND DR. CHARLES ASHLEY MANN
Entity type:Organization
Organization Name:DR. LEO A. HAYDT, IV AND DR. CHARLES ASHLEY MANN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:ALOYSIOUS
Authorized Official - Last Name:HAYDT
Authorized Official - Suffix:IV
Authorized Official - Credentials:DMD
Authorized Official - Phone:919-747-7888
Mailing Address - Street 1:1310 FIFTH AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3638
Mailing Address - Country:US
Mailing Address - Phone:919-747-7888
Mailing Address - Fax:
Practice Address - Street 1:1310 FIFTH AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3638
Practice Address - Country:US
Practice Address - Phone:919-747-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8911122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty