Healthcare Provider Details

I. General information

NPI: 1790050540
Provider Name (Legal Business Name): FAVIO ALBERTO LEON JR. RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 S. VERMONT AVE., #F WEST COAST DENTAL GROUP
LOS ANGELES CA
90007
US

IV. Provider business mailing address

133 N RENO ST APT 208
LOS ANGELES CA
90026-4678
US

V. Phone/Fax

Practice location:
  • Phone: 323-731-3333
  • Fax:
Mailing address:
  • Phone: 213-858-8748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number77346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: