Healthcare Provider Details

I. General information

NPI: 1649988007
Provider Name (Legal Business Name): LEIDY DIANA C MEZA RODRIGUEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 W CLINTON AVE
FRESNO CA
93705-3805
US

IV. Provider business mailing address

3800 STOCKER ST APT 29
VIEW PARK CA
90008-5121
US

V. Phone/Fax

Practice location:
  • Phone: 559-737-4710
  • Fax:
Mailing address:
  • Phone: 442-230-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033990
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: