Provider Demographics
NPI:1154318707
Name:LEONARD, WALTER PRUDDEN (DDS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:PRUDDEN
Last Name:LEONARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 W STATE ROAD 434
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4415
Mailing Address - Country:US
Mailing Address - Phone:407-788-1778
Mailing Address - Fax:407-788-7452
Practice Address - Street 1:2941 W STATE ROAD 434
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4415
Practice Address - Country:US
Practice Address - Phone:407-788-1778
Practice Address - Fax:407-788-7452
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN72861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice