Healthcare Provider Details

I. General information

NPI: 1811087257
Provider Name (Legal Business Name): JOHN WAYNE LEROY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4506 SE KING RD
MILWAUKIE OR
97222
US

IV. Provider business mailing address

4506 SE KING RD
MILWAUKIE OR
97222
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-1337
  • Fax: 503-659-6411
Mailing address:
  • Phone: 503-659-1337
  • Fax: 503-659-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5839
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: