Provider Demographics
NPI:1942725346
Name:SERRANO, LEONARDO (DMD)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:SERRANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:LEONARDO
Other - Middle Name:
Other - Last Name:SERRANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3026 CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6336 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33415-6104
Practice Address - Country:US
Practice Address - Phone:561-642-1177
Practice Address - Fax:561-642-1143
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024543800Medicaid