Provider Demographics
NPI:1477993087
Name:LEAL, GUSTAVO OMAR JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:OMAR
Last Name:LEAL
Suffix:JR
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 1:4400 HORIZON HILL BLVD
Mailing Address - Street 2:APT #4022
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2232
Mailing Address - Country:US
Mailing Address - Phone:956-639-4067
Mailing Address - Fax:
Practice Address - Street 1:1539 SW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1659
Practice Address - Country:US
Practice Address - Phone:956-639-4067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist