Provider Demographics
NPI:1265751770
Name:CARROLL, LESLIE ANN (DMD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:MEHALICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1677 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3044
Mailing Address - Country:US
Mailing Address - Phone:585-739-9691
Mailing Address - Fax:
Practice Address - Street 1:1428 W HEBRON PKWY
Practice Address - Street 2:SUITE #140
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6345
Practice Address - Country:US
Practice Address - Phone:972-394-1234
Practice Address - Fax:972-394-1154
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX287971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program