Provider Demographics
NPI:1275849507
Name:LEOPOLD, IAN (DDS)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:LEOPOLD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2725
Mailing Address - Country:US
Mailing Address - Phone:805-541-0550
Mailing Address - Fax:805-541-0485
Practice Address - Street 1:878 WALNUT ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2725
Practice Address - Country:US
Practice Address - Phone:805-541-0550
Practice Address - Fax:805-541-0485
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist