Provider Demographics
NPI:1083695100
Name:MCLEOD, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 IRVINE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4653
Mailing Address - Country:US
Mailing Address - Phone:949-548-8287
Mailing Address - Fax:949-548-8076
Practice Address - Street 1:2675 IRVINE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4653
Practice Address - Country:US
Practice Address - Phone:949-548-8287
Practice Address - Fax:949-548-8076
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA487471223P0300X
OK561223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics