=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548338684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY WAYNE LEONARD, JR. D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5329 NE M L KING BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97211-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-988-3664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25796 SW CANYON CREEK RD APT D304
-----------------------------------------------------
City | WILSONVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97070-9659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-682-5612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D7672
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------