Provider Demographics
NPI:1316469885
Name:LEIZEROVITZ, OLGA
Entity type:Individual
Prefix:DR
First Name:OLGA
Middle Name:
Last Name:LEIZEROVITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11795 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4188
Mailing Address - Country:US
Mailing Address - Phone:949-374-4243
Mailing Address - Fax:
Practice Address - Street 1:7426 CHERRY AVE STE 250
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4221
Practice Address - Country:US
Practice Address - Phone:909-355-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-16
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1013701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice