Provider Demographics
NPI:1710245782
Name:LEDESMA, MARK CHEVY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK CHEVY
Middle Name:S
Last Name:LEDESMA
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 1:319 N AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1346
Mailing Address - Country:US
Mailing Address - Phone:626-967-7727
Mailing Address - Fax:626-967-7887
Practice Address - Street 1:319 N AZUSA AVE.,
Practice Address - Street 2:
Practice Address - City:W COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791
Practice Address - Country:US
Practice Address - Phone:626-967-7727
Practice Address - Fax:626-967-7887
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist