Provider Demographics
NPI:1649323833
Name:PETERSON, LEONARD WINSLOW (DDS)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:WINSLOW
Last Name:PETERSON
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 1:10430 S DE ANZA BLVD
Mailing Address - Street 2:SUITE #140
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3019
Mailing Address - Country:US
Mailing Address - Phone:408-873-8484
Mailing Address - Fax:408-873-8459
Practice Address - Street 1:10430 S DE ANZA BLVD
Practice Address - Street 2:SUITE #140
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3019
Practice Address - Country:US
Practice Address - Phone:408-873-8484
Practice Address - Fax:408-873-8459
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD230201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37140Medicare UPIN