Provider Demographics
NPI:1063549228
Name:WOODSON, LESA RAE (DDS)
Entity type:Individual
Prefix:DR
First Name:LESA
Middle Name:RAE
Last Name:WOODSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LESA
Other - Middle Name:RAE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:10259 PEDRA DO SOL CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3475
Mailing Address - Country:US
Mailing Address - Phone:916-936-5154
Mailing Address - Fax:
Practice Address - Street 1:2400 MARITIME DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-3660
Practice Address - Country:US
Practice Address - Phone:916-686-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59194122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1856088Medicaid