Provider Demographics
NPI:1023220803
Name:LEONG, RICHARD WILSON JR (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILSON
Last Name:LEONG
Suffix:JR
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4422
Mailing Address - Country:US
Mailing Address - Phone:321-777-5201
Mailing Address - Fax:321-768-9643
Practice Address - Street 1:400 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1214
Practice Address - Country:US
Practice Address - Phone:321-723-7255
Practice Address - Fax:321-768-9643
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist