Provider Demographics
NPI:1073194650
Name:LEONARDO, ANGELICA SANDRA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:SANDRA
Last Name:LEONARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 CLAYTONIA RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1658
Mailing Address - Country:US
Mailing Address - Phone:516-710-8051
Mailing Address - Fax:
Practice Address - Street 1:8057 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9585
Practice Address - Country:US
Practice Address - Phone:315-698-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0625181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice