Provider Demographics
NPI:1558465609
Name:BERARD, LEO CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:CHARLES
Last Name:BERARD
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 1:2900 MANCHESTER ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909
Mailing Address - Country:US
Mailing Address - Phone:706-322-5418
Mailing Address - Fax:706-322-5424
Practice Address - Street 1:2900 MANCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:706-322-5418
Practice Address - Fax:706-322-5424
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN007838122300000X
FL10881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist