Provider Demographics
NPI:1992989180
Name:LEO, ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:LEO
Suffix:
Gender:M
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:PO BOX 750
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96127-0750
Mailing Address - Country:US
Mailing Address - Phone:530-251-5100
Mailing Address - Fax:530-251-5087
Practice Address - Street 1:475-750 RICE CANYON RD.
Practice Address - Street 2:HIGH DESERT STATE PRISON
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130
Practice Address - Country:US
Practice Address - Phone:530-251-5100
Practice Address - Fax:530-251-5087
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist