Provider Demographics
NPI:1285754465
Name:JOSE MARIO LEON-FRIAS
Entity type:Organization
Organization Name:JOSE MARIO LEON-FRIAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MARIO
Authorized Official - Last Name:LEON-FRIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSCD
Authorized Official - Phone:644-414-5533
Mailing Address - Street 1:P.O. BOX 2722
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85628-2722
Mailing Address - Country:US
Mailing Address - Phone:644-414-5533
Mailing Address - Fax:
Practice Address - Street 1:AV. LOPEZ MATEOS 171-2
Practice Address - Street 2:PLAZA AZTECA
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84000
Practice Address - Country:MX
Practice Address - Phone:631-312-5544
Practice Address - Fax:631-312-5545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMXN-0000070OtherSOUTHWEST SERVICE INC.