Healthcare Provider Details

I. General information

NPI: 1093909038
Provider Name (Legal Business Name): LEO LOU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8510 111 ST. APT#1003
EDMONTON ALBERTA
T6G 1H7
CA

IV. Provider business mailing address

8510 111 ST. APT#1003
EDMONTON ALBERTA
T6G 1H7
CA

V. Phone/Fax

Practice location:
  • Phone: 780-988-2345
  • Fax:
Mailing address:
  • Phone: 780-988-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21954
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: