Provider Demographics
NPI:1336279710
Name:DE LEON, MARK MENDEZ (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MENDEZ
Last Name:DE LEON
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 1:633 N CENTRAL AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-240-9142
Mailing Address - Fax:818-240-9127
Practice Address - Street 1:633 N CENTRAL AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-240-9142
Practice Address - Fax:818-240-9127
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist