Provider Demographics
NPI:1669638185
Name:PEREZ, LEONEL JR (DDS, MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:LEONEL
Middle Name:
Last Name:PEREZ
Suffix:JR
Gender:M
Credentials:DDS, MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24500 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2130
Mailing Address - Country:US
Mailing Address - Phone:210-542-1267
Mailing Address - Fax:
Practice Address - Street 1:7617 LITTLE RIVER TPKE STE 900
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2618
Practice Address - Country:US
Practice Address - Phone:703-936-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0090703261QM2500X
TX241311223S0112X
VA0101277440261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery