Healthcare Provider Details

I. General information

NPI: 1407919939
Provider Name (Legal Business Name): DENNIS MALCOLM MCLEOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LYNCH CREEK WY SUITE 9A
PETALUMA CA
94954
US

IV. Provider business mailing address

106 LYNCH CREEK WAY STE 9A
PETALUMA CA
94954-2356
US

V. Phone/Fax

Practice location:
  • Phone: 707-762-3561
  • Fax: 707-762-5174
Mailing address:
  • Phone: 707-778-7862
  • Fax: 707-778-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG22981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: