Provider Demographics
NPI:1730132358
Name:DELEON, ELADIO JR (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:ELADIO
Middle Name:
Last Name:DELEON
Suffix:JR
Gender:M
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:ELADIO
Other - Middle Name:
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, MS
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE GC-1012
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-7913
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-2421
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN87961223X0400X
GADNF0002751223X0400X
GADN1230061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000801028AMedicaid
SCZG0275Medicaid