Provider Demographics
NPI:1689681892
Name:FLETTRICH, LEON ALBERT III (DDS)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:ALBERT
Last Name:FLETTRICH
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 N CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-4708
Mailing Address - Country:US
Mailing Address - Phone:504-483-0955
Mailing Address - Fax:504-488-1814
Practice Address - Street 1:729 N CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-4708
Practice Address - Country:US
Practice Address - Phone:504-483-0955
Practice Address - Fax:504-488-1847
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA39101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU50841Medicare UPIN