Provider Demographics
NPI:1649781816
Name:LANDER, LEONARDO RAFAEL (DMD)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:RAFAEL
Last Name:LANDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 W 45TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3539
Mailing Address - Country:US
Mailing Address - Phone:954-404-0827
Mailing Address - Fax:
Practice Address - Street 1:1350 SW 160TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33326-1908
Practice Address - Country:US
Practice Address - Phone:954-651-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL226901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82-2124516OtherTAX ID