Healthcare Provider Details

I. General information

NPI: 1053152462
Provider Name (Legal Business Name): LEONEL VILLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV REVOLUVION Y CALLE 17
SAN LUIS RIO COLORADO SONORA
83448
MX

IV. Provider business mailing address

2013 DAIRY MART RD UNIT 3
SAN YSIDRO CA
92173-1848
US

V. Phone/Fax

Practice location:
  • Phone: 619-209-8924
  • Fax: 916-625-1368
Mailing address:
  • Phone: 619-209-8924
  • Fax: 916-625-1368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CLAIMS DENTAL DEPARMENT
Credential:
Phone: 619-209-8924