Healthcare Provider Details

I. General information

NPI: 1538185376
Provider Name (Legal Business Name): LEON ROBERT PECK DDS, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 WILSHIRE BLVD SUITE 815
BEVERLY HILLS CA
90211-3121
US

IV. Provider business mailing address

8500 WILSHIRE BLVD SUITE 815
BEVERLY HILLS CA
90211-3121
US

V. Phone/Fax

Practice location:
  • Phone: 310-657-6363
  • Fax: 310-652-5785
Mailing address:
  • Phone: 310-657-6363
  • Fax: 310-652-5785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number38348
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number38348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: