1255066379 NPI number — RYAN DRAKE NEPOMUCENO DE LEON DMD

Table of content: RYAN DRAKE NEPOMUCENO DE LEON DMD (NPI 1255066379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255066379 NPI number — RYAN DRAKE NEPOMUCENO DE LEON DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LEON
Provider First Name:
RYAN DRAKE
Provider Middle Name:
NEPOMUCENO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255066379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2162 GARNET CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94591-8375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-315-2210
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10316 MASON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATSWORTH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91311-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-493-1302
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  107638 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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