Basic Information
| Provider Information | |||||||||
| NPI: | 1194975714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 FRANCE AVE S STE 415 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522249771 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 HIGHWAY 29 S STE 4176 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563084540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635052 | ||||||||
| FaxNumber: | 3207635053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 09/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D9921 | MN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 207320000 | 05 | MN | MEDICAID |