Provider Demographics
NPI:1649798935
Name:LEIST, JONATHAN BLAKE (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BLAKE
Last Name:LEIST
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 1:2359 WHEATLANDS DR
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2134
Mailing Address - Country:US
Mailing Address - Phone:757-812-2309
Mailing Address - Fax:
Practice Address - Street 1:1138 ROSE HILL DR STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-5128
Practice Address - Country:US
Practice Address - Phone:434-972-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014157301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice