Provider Demographics
NPI:1790798270
Name:DANTAS, LEONORA BALBUENA (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONORA
Middle Name:BALBUENA
Last Name:DANTAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LEONORA
Other - Middle Name:BALBUENA
Other - Last Name:MANZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:503-636-0763
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-331-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORORMD0277204D00000X
WAWAMD00034628204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM