Healthcare Provider Details

I. General information

NPI: 1184315152
Provider Name (Legal Business Name): LEANDRE DANIEL GERVAIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEANDRE D GERVAIS DDS

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 PHOENIX BLVD STE 100
COLLEGE PARK GA
30349-5062
US

IV. Provider business mailing address

1000 BLYTHE BLVD, CHARLOTTE
ATLANTA NC
28203-5812
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-0913
  • Fax:
Mailing address:
  • Phone: 704-355-2165
  • Fax: 704-355-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123399
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number151483
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: