=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043480841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM LEON DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2008
-----------------------------------------------------
Last Update Date | 03/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6209 42ND AVE N
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-537-7057
-----------------------------------------------------
Fax | 763-535-5038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6209 42ND AVE N
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-537-7057
-----------------------------------------------------
Fax | 763-535-5038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. WILLIAM LEON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 763-537-7057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D12001
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------