Provider Demographics
NPI:1104910694
Name:LEONARD, JERRY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:LEONARD
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 1:985 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-6211
Mailing Address - Country:US
Mailing Address - Phone:301-926-2928
Mailing Address - Fax:
Practice Address - Street 1:985 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-6211
Practice Address - Country:US
Practice Address - Phone:301-926-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54881223S0112X
MD174071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty