MEDICARE: DR. ALEXANDER LEONOV D.D.S

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	1223G0001X	General Practice Dentistry	36127	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B36127-01	OTHER	CA	DENTICAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1932192960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER LEONOV D.D.S

Provider Business Mailing Address
First Line	:	13112 SHERMAN WAY
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-4645
Country	:	US
Telephone Number	:	818-982-6162
Fax Number	:	818-982-6214

Provider Business Practice Location Address
First Line	:	13112 SHERMAN WAY
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-4645
Country	:	US
Telephone Number	:	818-982-6162
Fax Number	:	818-982-6214

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

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	08/13/2013

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