Provider Demographics
NPI:1184315152
Name:GERVAIS, LEANDRE DANIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:LEANDRE
Middle Name:DANIEL
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:LEANDRE
Other - Middle Name:D
Other - Last Name:GERVAIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1000 BLYTHE BLVD, CHARLOTTE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-355-2165
Mailing Address - Fax:704-355-8856
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2165
Practice Address - Fax:704-355-8856
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123399122300000X
390200000X
GADN12399390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist