MEDICARE: DR. JERRY WAYNE LEONARD, JR. D.M.D.

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	122300000X	Dentist	D7672	OR

General Provider Information

NPI Number	:	1548338684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY WAYNE LEONARD, JR. D.M.D.

Provider Business Mailing Address
First Line	:	25796 SW CANYON CREEK RD
Second Line	:	APT D304
City	:	WILSONVILLE
State	:	OR
Zip	:	97070-9659
Country	:	US
Telephone Number	:	503-682-5612
Fax Number	:

Provider Business Practice Location Address
First Line	:	5329 NE M L KING BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3237
Country	:	US
Telephone Number	:	503-988-3664
Fax Number	:

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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