MEDICARE: MRS. IVA LEROY DDS

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	1223P0221X	Pediatric Dentistry	22DI02569800	NJ

General Provider Information

NPI Number	:	1528350642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IVA LEROY DDS

Provider Business Mailing Address
First Line	:	34 LORRAINE ST
Second Line	:
City	:	GLEN RIDGE
State	:	NJ
Zip	:	07028-2028
Country	:	US
Telephone Number	:	646-717-3573
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 PLEASANT VALLEY WAY
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-2988
Country	:	US
Telephone Number	:	646-717-3573
Fax Number	:

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

Provider Enumeration Date	:	05/08/2011
Last Update Date	:	05/07/2018

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