Provider Demographics
NPI:1861594533
Name:LEATHERMAN, THOMAS G (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:LEATHERMAN
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 1:6100 S BROADWAY
Mailing Address - Street 2:SUITE #300
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3874
Mailing Address - Country:US
Mailing Address - Phone:440-233-8521
Mailing Address - Fax:440-233-8523
Practice Address - Street 1:6100 S BROADWAY
Practice Address - Street 2:SUITE #300
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3874
Practice Address - Country:US
Practice Address - Phone:440-233-8521
Practice Address - Fax:440-233-8523
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice