Provider Demographics
NPI:1033368402
Name:LEON-FRIAS, JOSE MARIO (DDS MSCD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MARIO
Last Name:LEON-FRIAS
Suffix:
Gender:M
Credentials:DDS MSCD
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 2722
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85628-2722
Mailing Address - Country:US
Mailing Address - Phone:011-526-4441
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA LOPEZ MATEOS 171-2
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84000
Practice Address - Country:MX
Practice Address - Phone:01152631-312-5544
Practice Address - Fax:01152631-312-5545
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ10728371223G0001X
ZZAEIE064291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMXN000070OtherSOUTHWEST SERVICE ADMINISTRATORS