Healthcare Provider Details

I. General information

NPI: 1902862493
Provider Name (Legal Business Name): LEANDRA MOORE S. ANTONIO-JOSE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEANDRA DOPAZO D.D.S.

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3457 HENDRICKS AVE
JACKSONVILLE FL
32207-5307
US

IV. Provider business mailing address

3457 HENDRICKS AVE
JACKSONVILLE FL
32207-5307
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-6461
  • Fax: 904-398-3177
Mailing address:
  • Phone: 904-398-6461
  • Fax: 904-398-3177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: