Provider Demographics
NPI:1992701957
Name:LEAF, ELLEN BRACKETT (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:BRACKETT
Last Name:LEAF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 W 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2298
Mailing Address - Country:US
Mailing Address - Phone:650-345-1991
Mailing Address - Fax:650-345-1307
Practice Address - Street 1:190 W 25TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2298
Practice Address - Country:US
Practice Address - Phone:650-345-1991
Practice Address - Fax:650-345-1307
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CA328691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice