Provider Demographics
NPI:1194241604
Name:PALACIOS, SERGIO LEONIDAS (DDS)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:LEONIDAS
Last Name:PALACIOS
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 1:4700 SW ARCHER RD APT E38
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3886
Mailing Address - Country:US
Mailing Address - Phone:786-260-8934
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR APT D8-18
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15961223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology