Provider Demographics
NPI:1659418366
Name:LEAL, GUSTAVO A (DDS)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:A
Last Name:LEAL
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 1:12300 SOUTHSHORE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6237
Mailing Address - Country:US
Mailing Address - Phone:561-204-4494
Mailing Address - Fax:561-204-2840
Practice Address - Street 1:12300 SOUTHSHORE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6237
Practice Address - Country:US
Practice Address - Phone:561-204-4494
Practice Address - Fax:561-204-2840
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice