MEDICARE: WALTER PRUDDEN LEONARD DDS

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	DN7286	FL

General Provider Information

NPI Number	:	1154318707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER PRUDDEN LEONARD DDS

Provider Business Mailing Address
First Line	:	2941 W STATE ROAD 434
Second Line	:	SUITE 200
City	:	LONGWOOD
State	:	FL
Zip	:	32779-4415
Country	:	US
Telephone Number	:	407-788-1778
Fax Number	:	407-788-7452

Provider Business Practice Location Address
First Line	:	2941 W STATE ROAD 434
Second Line	:	SUITE 200
City	:	LONGWOOD
State	:	FL
Zip	:	32779-4415
Country	:	US
Telephone Number	:	407-788-1778
Fax Number	:	407-788-7452

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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