Provider Demographics
NPI:1801122130
Name:LEONARD, MARCELLA BORGMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARCELLA
Middle Name:BORGMAN
Last Name:LEONARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARCELLA
Other - Middle Name:SUSANNE
Other - Last Name:BORGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist