Provider Demographics
NPI:1750423281
Name:LEONI, RUSSEL GUSTAF (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:GUSTAF
Last Name:LEONI
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:PSC 475
Mailing Address - Street 2:BOX 1738
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 475
Practice Address - Street 2:BOX 1738
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350
Practice Address - Country:US
Practice Address - Phone:011815-513-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD88851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice