Provider Demographics
NPI:1417142316
Name:DE LEON, ROSSANNA (DDS)
Entity Type:Individual
Prefix:
First Name:ROSSANNA
Middle Name:
Last Name:DE LEON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 S 5TH ST APT 22
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-6463
Mailing Address - Country:US
Mailing Address - Phone:718-384-4210
Mailing Address - Fax:
Practice Address - Street 1:356 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7309
Practice Address - Country:US
Practice Address - Phone:718-384-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0501181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02408813Medicaid