Provider Demographics
NPI:1477686962
Name:GROSS, LESLIE RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:RAYMOND
Last Name:GROSS
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 1:777 W GERMANTOWN PIKE APT 923
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1022
Mailing Address - Country:US
Mailing Address - Phone:610-279-7292
Mailing Address - Fax:
Practice Address - Street 1:722 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2312
Practice Address - Country:US
Practice Address - Phone:215-922-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist