Provider Demographics
NPI:1225760358
Name:CARRILLO, LESLEY VANESSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:VANESSA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7003
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:
Practice Address - Street 1:2975 ZOE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5278
Practice Address - Country:US
Practice Address - Phone:323-826-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1079201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program