Provider Demographics
NPI:1174731087
Name:LEO, JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LEO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1982 LIVERNOIS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1734
Mailing Address - Country:US
Mailing Address - Phone:248-524-2828
Mailing Address - Fax:248-524-9666
Practice Address - Street 1:1982 LIVERNOIS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1734
Practice Address - Country:US
Practice Address - Phone:248-524-2828
Practice Address - Fax:248-524-9666
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist