Provider Demographics
NPI:1861523748
Name:LESLIE, ALTUS HARVEY (DMD)
Entity type:Individual
Prefix:DR
First Name:ALTUS
Middle Name:HARVEY
Last Name:LESLIE
Suffix:
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 1:328 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-3215
Mailing Address - Country:US
Mailing Address - Phone:662-801-6161
Mailing Address - Fax:
Practice Address - Street 1:202 MEADOWLANE ST
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2219
Practice Address - Country:US
Practice Address - Phone:662-258-2461
Practice Address - Fax:662-258-2408
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2185-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice