Provider Demographics
NPI:1346085842
Name:MEZA, LEOBARDO
Entity type:Individual
Prefix:
First Name:LEOBARDO
Middle Name:
Last Name:MEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 E SAN YSIDRO BLVD STE 128
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3123
Mailing Address - Country:US
Mailing Address - Phone:619-831-0437
Mailing Address - Fax:619-785-3404
Practice Address - Street 1:17633 S AVENUE B
Practice Address - Street 2:
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350-8289
Practice Address - Country:US
Practice Address - Phone:619-831-0437
Practice Address - Fax:619-785-3404
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ42818571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice