Healthcare Provider Details

I. General information

NPI: 1073072872
Provider Name (Legal Business Name): LEILA ZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 11/10/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

5835 E STILL CIR
MESA AZ
85206-3618
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-8100
  • Fax:
Mailing address:
  • Phone: 480-248-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD010809
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: