Provider Demographics
NPI:1740497965
Name:PLATOCK, LESLIE G (DDS)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:G
Last Name:PLATOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 3RD ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-5072
Mailing Address - Country:US
Mailing Address - Phone:904-247-3077
Mailing Address - Fax:904-247-3078
Practice Address - Street 1:700 3RD ST
Practice Address - Street 2:SUITE 203
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5072
Practice Address - Country:US
Practice Address - Phone:904-247-3077
Practice Address - Fax:904-247-3078
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice