MEDICARE: DR. MARIA PATROCINIO DE LEON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	45240	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1879369	OTHER		UNITED CONCORDIA
2	G-94004-01	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1376601211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA PATROCINIO DE LEON D.D.S.

Provider Business Mailing Address
First Line	:	1942 HARBOR BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2669
Country	:	US
Telephone Number	:	949-631-1000
Fax Number	:	949-631-0350

Provider Business Practice Location Address
First Line	:	1942 HARBOR BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2669
Country	:	US
Telephone Number	:	949-631-1000
Fax Number	:	949-631-0350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	03/07/2023

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