Provider Demographics
NPI:1174108062
Name:MAYO-SMITH, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MAYO-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEADOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03235-2118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 POST OFFICE SQ
Practice Address - Street 2:
Practice Address - City:LYNNFIELD
Practice Address - State:MA
Practice Address - Zip Code:01940-2263
Practice Address - Country:US
Practice Address - Phone:781-592-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18590331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty