MEDICARE: BURBANK VILLAGE DENTISTRY

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1780706267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURBANK VILLAGE DENTISTRY

Provider Business Mailing Address
First Line	:	928 N SAN FERNANDO BLVD
Second Line	:	E
City	:	BURBANK
State	:	CA
Zip	:	91504-4350
Country	:	US
Telephone Number	:	818-841-8607
Fax Number	:	818-841-8414

Provider Business Practice Location Address
First Line	:	928 N SAN FERNANDO BLVD
Second Line	:	E
City	:	BURBANK
State	:	CA
Zip	:	91504-4350
Country	:	US
Telephone Number	:	818-841-8607
Fax Number	:	818-841-8414

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDER LEONOV
Credential	:	D.D.S
Telephone Number	:	818-841-8607

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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Directions to “BURBANK VILLAGE DENTISTRY ” Practice Location

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