Provider Demographics
NPI:1740243195
Name:LEO, CHARLES M (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:LEO
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 1:103 WINDWATCH DR
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3349
Mailing Address - Country:US
Mailing Address - Phone:631-232-0706
Mailing Address - Fax:
Practice Address - Street 1:103 WINDWATCH DR
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3349
Practice Address - Country:US
Practice Address - Phone:631-232-0706
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice