Provider Demographics
NPI:1609889930
Name:WHEAT, LEO JR (DMD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:WHEAT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 JEFFERSON PKWY
Mailing Address - Street 2:SUITE A AND B
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5813
Mailing Address - Country:US
Mailing Address - Phone:770-252-9345
Mailing Address - Fax:770-252-9347
Practice Address - Street 1:51 JEFFERSON PKWY
Practice Address - Street 2:SUITE A AND B
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5813
Practice Address - Country:US
Practice Address - Phone:770-252-9345
Practice Address - Fax:770-252-9347
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0112711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000691204AMedicaid
GA000691204BMedicaid