MEDICARE: ANTHONY GERARD LEISURE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2026000064	MO

General Provider Information

NPI Number	:	1013768415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY GERARD LEISURE JR.

Provider Business Mailing Address
First Line	:	938 CASTLE PINES DR
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63021-4475
Country	:	US
Telephone Number	:	314-707-7608
Fax Number	:

Provider Business Practice Location Address
First Line	:	11941 MANCHESTER RD
Second Line	:
City	:	DES PERES
State	:	MO
Zip	:	63131-4502
Country	:	US
Telephone Number	:	314-501-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	03/24/2026

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