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General NPI Number Information
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NPI Number | 1225760358
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Entity Type | Individual
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Provider Name | LESLEY VANESSA CARRILLO DMD
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Gender | Female
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Dates
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Enumeration Date | 06/28/2022
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Last Update Date | 09/02/2022
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Provider Practice Location Address
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Address Line | 2975 ZOE AVE
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City | HUNTINGTON PARK
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State | CA
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Zip | 90255-5278
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Country | US
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Telephone | 323-826-9449
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 W MAIN ST STE 301
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City | ALHAMBRA
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State | CA
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Zip | 91801-7003
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Country | US
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Telephone | 626-457-6900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 107920
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License Number State | CA
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