MEDICARE: DR. LEON ROBERT PECK DDS, PH.D.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	38348	CA
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	38348	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538185376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEON ROBERT PECK DDS, PH.D.

Provider Business Mailing Address
First Line	:	8500 WILSHIRE BLVD
Second Line	:	SUITE 815
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-3121
Country	:	US
Telephone Number	:	310-657-6363
Fax Number	:	310-652-5785

Provider Business Practice Location Address
First Line	:	8500 WILSHIRE BLVD
Second Line	:	SUITE 815
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-3121
Country	:	US
Telephone Number	:	310-657-6363
Fax Number	:	310-652-5785

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	11/20/2009

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