Healthcare Provider Details

I. General information

NPI: 1972009959
Provider Name (Legal Business Name): LEILA HAZAVEI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S STATE RD STE 300
SPRINGFIELD PA
19064-1232
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 610-622-1949
  • Fax:
Mailing address:
  • Phone: 718-920-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02808900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS042600
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: