Provider Demographics
NPI:1588288138
Name:KRUK-LEAHY, DANIEL (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:KRUK-LEAHY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 WASHINGTON BLVD APT 410
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-4211
Mailing Address - Country:US
Mailing Address - Phone:213-364-9120
Mailing Address - Fax:
Practice Address - Street 1:1401 AVOCADO AVE STE 404
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7783
Practice Address - Country:US
Practice Address - Phone:213-364-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1064021223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97706578F90105Medicaid