Provider Demographics
NPI:1366909046
Name:LEISURE DENTAL
Entity type:Organization
Organization Name:LEISURE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGGERTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-991-5166
Mailing Address - Street 1:4316 HILLINGDON BND APT 102
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2458
Mailing Address - Country:US
Mailing Address - Phone:214-991-5166
Mailing Address - Fax:757-222-5137
Practice Address - Street 1:7870 TIDEWATER DR UNIT 202-203
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3713
Practice Address - Country:US
Practice Address - Phone:757-222-3880
Practice Address - Fax:757-222-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental