Provider Demographics
NPI:1073236667
Name:LESLIE FABIOLA GONZALEZ VEGA
Entity Type:Organization
Organization Name:LESLIE FABIOLA GONZALEZ VEGA
Other - Org Name:MEJIA DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:FABIOLA
Authorized Official - Last Name:GONZALEZ VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-586-3847
Mailing Address - Street 1:200 VAN HOUTEN AVE APT 133
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-4431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ARGUELLO 1908
Practice Address - Street 2:ZONA CENTRO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:619-272-9021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty