Provider Demographics
NPI:1316040819
Name:VELEZ-LEON, WALESKA I (DMD)
Entity Type:Individual
Prefix:
First Name:WALESKA
Middle Name:I
Last Name:VELEZ-LEON
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 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-654-4528
Practice Address - Street 1:13275 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3984
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-654-4528
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0013300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004764200Medicaid