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General NPI Number Information
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NPI Number | 1427566553
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Entity Type | Organization
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Legal Business Name | GREENLEAF DENTAL SPA
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Dates
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Enumeration Date | 01/10/2018
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Last Update Date | 04/22/2019
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Provider Practice Location Address
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Address Line | 1758 SIERRA LEONE AVE STE C
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-5837
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Country | US
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Telephone | 626-695-7448
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Fax | 626-695-7448
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Provider Business Mailing Address
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Address Line | 1758 SIERRA LEONE AVE STE C
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-5837
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Country | US
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Telephone | 626-695-7448
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Fax | 626-964-6681
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Authorized Official
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Title or Position | MANAGER
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Name | MS. CECILLIA TU
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Credential |
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Telephone | 626-695-7448
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 56784
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License Number State | CA
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