Provider Demographics
NPI:1578678983
Name:LEONARD, JERRY WAYNE SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WAYNE
Last Name:LEONARD
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4816
Mailing Address - Country:US
Mailing Address - Phone:503-284-8114
Mailing Address - Fax:
Practice Address - Street 1:2614 NE 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4816
Practice Address - Country:US
Practice Address - Phone:503-284-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR51931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice