Healthcare Provider Details

I. General information

NPI: 1356316871
Provider Name (Legal Business Name): LEEANN WANDA KARDOSH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 ENCINITAS BLVD STE 101
ENCINITAS CA
92024-3782
US

IV. Provider business mailing address

531 ENCINITAS BLVD STE 101
ENCINITAS CA
92024-3782
US

V. Phone/Fax

Practice location:
  • Phone: 760-944-0048
  • Fax: 623-878-1024
Mailing address:
  • Phone: 760-944-0048
  • Fax: 760-944-1432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8774
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number58396
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019189
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: