Provider Demographics
NPI:1679104129
Name:MCLEOD, MATTHEW DENZEL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DENZEL
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6512 SAND LAKE SOUND RD UNIT 2202
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7509
Mailing Address - Country:US
Mailing Address - Phone:631-708-4499
Mailing Address - Fax:
Practice Address - Street 1:13559 NARCOOSSEE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-7136
Practice Address - Country:US
Practice Address - Phone:407-476-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL267761223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program