1821637638 NPI number — RICHARD WILSON LEONG JR DDS PA

Table of content: LYNETTE VANNOSTRAND BA, AS, RDH, PHDHP (NPI 1376952416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821637638 NPI number — RICHARD WILSON LEONG JR DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD WILSON LEONG JR DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821637638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 S BABCOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-1214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-723-7255
Provider Business Mailing Address Fax Number:
321-768-9643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S BABCOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-723-7255
Provider Business Practice Location Address Fax Number:
321-768-9643
Provider Enumeration Date:
12/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LEONG
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
WILSON
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
321-723-7255

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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