Healthcare Provider Details

I. General information

NPI: 1285754465
Provider Name (Legal Business Name): JOSE MARIO LEON-FRIAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. LOPEZ MATEOS 171-2 PLAZA AZTECA
NOGALES SONORA
84000
MX

IV. Provider business mailing address

P.O. BOX 2722
NOGALES AZ
85628-2722
US

V. Phone/Fax

Practice location:
  • Phone: 631-312-5544
  • Fax: 631-312-5545
Mailing address:
  • Phone: 644-414-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOSE MARIO LEON-FRIAS
Title or Position: OWNER
Credential: DDS, MSCD
Phone: 644-414-5533