Provider Demographics
NPI:1043568694
Name:NICK LEONE DDS PC
Entity Type:Organization
Organization Name:NICK LEONE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-775-7750
Mailing Address - Street 1:28018 HARPER AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28018 HARPER AVE.
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1562
Practice Address - Country:US
Practice Address - Phone:586-775-7750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010134801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty