Healthcare Provider Details

I. General information

NPI: 1568686475
Provider Name (Legal Business Name): LEROY LANCE DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 IRVINE BLVD STE 205
TUSTIN CA
92780-3402
US

IV. Provider business mailing address

18102 IRVINE BLVD STE 205
TUSTIN CA
92780-3402
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-5656
  • Fax: 714-731-2607
Mailing address:
  • Phone: 714-731-5656
  • Fax: 714-731-2607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number15075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: