Healthcare Provider Details

I. General information

NPI: 1013768415
Provider Name (Legal Business Name): ANTHONY GERARD LEISURE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11941 MANCHESTER RD
DES PERES MO
63131-4502
US

IV. Provider business mailing address

938 CASTLE PINES DR
BALLWIN MO
63021-4475
US

V. Phone/Fax

Practice location:
  • Phone: 314-501-8300
  • Fax:
Mailing address:
  • Phone: 314-707-7608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2026000064
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: