Provider Demographics
NPI:1316945751
Name:LEASE, GARY MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:LEASE
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:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32704-1249
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:1296 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-2012
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:352-429-1257
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071836000Medicaid