Provider Demographics
NPI:1063493500
Name:FUQUA, LEONARD RAY JR (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:RAY
Last Name:FUQUA
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:505 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2630
Mailing Address - Country:US
Mailing Address - Phone:865-376-4445
Mailing Address - Fax:865-376-4441
Practice Address - Street 1:505 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2630
Practice Address - Country:US
Practice Address - Phone:865-376-4445
Practice Address - Fax:865-376-4441
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000029171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics