Healthcare Provider Details

I. General information

NPI: 1649196692
Provider Name (Legal Business Name): LESLIE HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S MOUNT VERNON AVE
COLTON CA
92324-3928
US

IV. Provider business mailing address

9460 PALMETTO AVE
FONTANA CA
92335-5969
US

V. Phone/Fax

Practice location:
  • Phone: 909-660-0097
  • Fax:
Mailing address:
  • Phone: 909-368-5141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number393348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: