Provider Demographics
NPI:1194054866
Name:A PROFESSIONAL DENTAL CORPORATION ALEXANDER LEONOV DDS
Entity type:Organization
Organization Name:A PROFESSIONAL DENTAL CORPORATION ALEXANDER LEONOV DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-841-8607
Mailing Address - Street 1:928 N SAN FERNANDO BLVD
Mailing Address - Street 2:E
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504
Mailing Address - Country:US
Mailing Address - Phone:818-841-8607
Mailing Address - Fax:818-841-8414
Practice Address - Street 1:928 N SAN FERNANDO BLVD
Practice Address - Street 2:E
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-4350
Practice Address - Country:US
Practice Address - Phone:818-841-8607
Practice Address - Fax:818-841-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36127261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental