Provider Demographics
NPI:1790747061
Name:PACKTOR, LEONARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:PACKTOR
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 1:9410A WILLEO RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4717
Mailing Address - Country:US
Mailing Address - Phone:770-993-2657
Mailing Address - Fax:770-998-2512
Practice Address - Street 1:9410A WILLEO RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4717
Practice Address - Country:US
Practice Address - Phone:770-993-2657
Practice Address - Fax:770-998-2512
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00094621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice