Healthcare Provider Details

I. General information

NPI: 1225760358
Provider Name (Legal Business Name): LESLEY VANESSA CARRILLO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 ZOE AVE
HUNTINGTON PARK CA
90255-5278
US

IV. Provider business mailing address

2550 W MAIN ST STE 301
ALHAMBRA CA
91801-7003
US

V. Phone/Fax

Practice location:
  • Phone: 323-826-9449
  • Fax:
Mailing address:
  • Phone: 626-457-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number107920
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: