Provider Demographics
NPI:1902862493
Name:ANTONIO-JOSE, LEANDRA MOORE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEANDRA
Middle Name:MOORE S
Last Name:ANTONIO-JOSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LEANDRA
Other - Middle Name:
Other - Last Name:DOPAZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3457 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5307
Mailing Address - Country:US
Mailing Address - Phone:904-398-6461
Mailing Address - Fax:904-398-3177
Practice Address - Street 1:3457 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5307
Practice Address - Country:US
Practice Address - Phone:904-398-6461
Practice Address - Fax:904-398-3177
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 187191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics