Healthcare Provider Details

I. General information

NPI: 1629437991
Provider Name (Legal Business Name): KEVIN LEONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14815 W BELL RD STE 202
SURPRISE AZ
85374-7611
US

IV. Provider business mailing address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

V. Phone/Fax

Practice location:
  • Phone: 623-547-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011885
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: