Provider Demographics
NPI:1447937107
Name:LEIVA CARDONA, EDGARDO A (DDS)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:A
Last Name:LEIVA CARDONA
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 1:131 3RD AVE APT B
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3143
Mailing Address - Country:US
Mailing Address - Phone:305-778-7105
Mailing Address - Fax:
Practice Address - Street 1:2000 S PATRICK DR STE 1
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4462
Practice Address - Country:US
Practice Address - Phone:321-773-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist