Provider Demographics
NPI:1487864492
Name:DE LEON, ELMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELMER
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1581 SYCAMORE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1700
Mailing Address - Country:US
Mailing Address - Phone:510-799-2900
Mailing Address - Fax:510-799-2902
Practice Address - Street 1:1581 SYCAMORE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1700
Practice Address - Country:US
Practice Address - Phone:510-799-2900
Practice Address - Fax:510-799-2902
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist