Provider Demographics
NPI:1053765925
Name:LEACH, MATTHEW THOMAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:LEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 TATE BLVD SE STE 204
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4216
Mailing Address - Country:US
Mailing Address - Phone:828-855-3779
Mailing Address - Fax:828-855-3781
Practice Address - Street 1:530 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-3238
Practice Address - Country:US
Practice Address - Phone:704-564-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC113321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program