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General NPI Number Information
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NPI Number | 1699177642
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Entity Type | Organization
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Legal Business Name | TIMOTHY LEETRAKUL DDS DENTAL CORPORATION
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Dates
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Enumeration Date | 09/22/2014
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Last Update Date | 06/02/2021
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Provider Practice Location Address
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Address Line | 12643 SHERMAN WAY STE D
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91605-5271
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Country | US
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Telephone | 818-765-3534
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Fax | 818-765-3537
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Provider Business Mailing Address
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Address Line | 12643 SHERMAN WAY STE D
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91605-5271
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Country | US
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Telephone | 818-765-3534
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Fax | 818-765-3537
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIMOTHY LEETRAKUL
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Credential | DDS
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Telephone | 818-765-3534
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 58017
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License Number State | CA
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