MEDICARE: DR. LEONARD CARL MEDURA SR. D.D.S

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	DS017342L	PA

General Provider Information

NPI Number	:	1912906603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEONARD CARL MEDURA SR. D.D.S

Provider Business Mailing Address
First Line	:	21 WELLINGTON RD
Second Line	:
City	:	SHAVERTOWN
State	:	PA
Zip	:	18708-1341
Country	:	US
Telephone Number	:	570-675-1138
Fax Number	:	570-675-2152

Provider Business Practice Location Address
First Line	:	1 TARLETON AVE
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-1248
Country	:	US
Telephone Number	:	570-675-1138
Fax Number	:	570-675-2152

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	05/11/2017

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