Healthcare Provider Details

I. General information

NPI: 1720468929
Provider Name (Legal Business Name): ESDL DE LEON DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 B ST
HAYWARD CA
94541-2917
US

IV. Provider business mailing address

1375 B ST
HAYWARD CA
94541-2917
US

V. Phone/Fax

Practice location:
  • Phone: 510-582-8277
  • Fax: 510-582-0305
Mailing address:
  • Phone: 510-582-8277
  • Fax: 510-582-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55619
License Number StateCA

VIII. Authorized Official

Name: DR. ELMER SANTOS DE LEON
Title or Position: PRESIDENT
Credential: DDS
Phone: 510-396-2703