MEDICARE: DE LEON DENTISTRY GENERAL & COSMESTIC

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

General Provider Information

NPI Number	:	1548642846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE LEON DENTISTRY GENERAL & COSMESTIC

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

Authorized Official
Title or Position	:	D.D.S (DENTIST)
Name	:	MARIA P DE LEON
Credential	:
Telephone Number	:	949-631-1000

Provider Enumeration Date	:	06/23/2015
Last Update Date	:	06/23/2015

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