Provider Demographics
NPI:1811087257
Name:LEROY, JOHN WAYNE (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:LEROY
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 1:4506 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-659-1337
Mailing Address - Fax:503-659-6411
Practice Address - Street 1:4506 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-659-1337
Practice Address - Fax:503-659-6411
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice