Provider Demographics
NPI:1225175268
Name:DURRETT, LEO J JR (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:J
Last Name:DURRETT
Suffix:JR
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 15TH LANE, NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:727-576-0037
Mailing Address - Fax:
Practice Address - Street 1:8600 15TH LANE, NORTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-576-0037
Practice Address - Fax:727-576-0037
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN60091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics