Healthcare Provider Details

I. General information

NPI: 1346085842
Provider Name (Legal Business Name): LEOBARDO MEZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17633 S AVENUE B
SOMERTON AZ
85350-8289
US

IV. Provider business mailing address

710 E SAN YSIDRO BLVD STE 128
SAN YSIDRO CA
92173-3123
US

V. Phone/Fax

Practice location:
  • Phone: 619-831-0437
  • Fax: 619-785-3404
Mailing address:
  • Phone: 619-831-0437
  • Fax: 619-785-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4281857
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: