MEDICARE: DR. MARIVIC DE LEON DMD, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	S6-234	NV

General Provider Information

NPI Number	:	1588337489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIVIC DE LEON DMD, MPH

Provider Business Mailing Address
First Line	:	3600 N BUFFALO DR STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7462
Country	:	US
Telephone Number	:	702-254-8858
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 N BUFFALO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7463
Country	:	US
Telephone Number	:	702-254-8858
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	01/31/2025

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