Provider Demographics
NPI:1912046871
Name:LEON D. ROISMAN, D.M.D., INC.
Entity type:Organization
Organization Name:LEON D. ROISMAN, D.M.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-432-4242
Mailing Address - Street 1:310 S LAKE AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3540
Mailing Address - Country:US
Mailing Address - Phone:626-795-6855
Mailing Address - Fax:626-432-4260
Practice Address - Street 1:310 S LAKE AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3540
Practice Address - Country:US
Practice Address - Phone:626-795-6855
Practice Address - Fax:626-432-4260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB19960-01OtherDENTICAL