Healthcare Provider Details

I. General information

NPI: 1619724598
Provider Name (Legal Business Name): LESLIE CEDILLO VERLAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 CEDAR AVE
LAREDO TX
78040-4040
US

IV. Provider business mailing address

7430 HARPER LEE DR
LAREDO TX
78041-2153
US

V. Phone/Fax

Practice location:
  • Phone: 956-523-7500
  • Fax:
Mailing address:
  • Phone: 956-678-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number42911
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: