Provider Demographics
NPI:1326118993
Name:PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-778-7100
Mailing Address - Street 1:1439 STILLWATER AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7367
Mailing Address - Country:US
Mailing Address - Phone:307-778-7100
Mailing Address - Fax:307-778-2824
Practice Address - Street 1:1439 STILLWATER AVE STE 7
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7367
Practice Address - Country:US
Practice Address - Phone:307-778-7100
Practice Address - Fax:307-778-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY974672OtherUNITED CONCORDIA CO