Provider Demographics
NPI:1679886923
Name:BRADY, LEAH NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:NICOLE
Last Name:BRADY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3536
Mailing Address - Country:US
Mailing Address - Phone:701-667-1933
Mailing Address - Fax:701-667-2115
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3536
Practice Address - Country:US
Practice Address - Phone:701-667-1933
Practice Address - Fax:701-667-2115
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20701223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457027Medicaid