Provider Demographics
NPI:1164794244
Name:LEONARD, JAMES WAYNE (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WAYNE
Last Name:LEONARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:WAYNE
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2233 COUNTY ROAD 210 W
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4019
Mailing Address - Country:US
Mailing Address - Phone:904-217-7202
Mailing Address - Fax:
Practice Address - Street 1:2233 COUNTY ROAD 210 W
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4019
Practice Address - Country:US
Practice Address - Phone:904-217-7202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00146071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice