Healthcare Provider Details

I. General information

NPI: 1336004456
Provider Name (Legal Business Name): LEONARDO GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10445 LAUREL CANYON BLVD
PACOIMA CA
91331-3605
US

IV. Provider business mailing address

10445 LAUREL CANYON BLVD
PACOIMA CA
91331-3605
US

V. Phone/Fax

Practice location:
  • Phone: 818-472-5609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: