Provider Demographics
NPI:1790050540
Name:LEON, FAVIO ALBERTO JR (RDA)
Entity Type:Individual
Prefix:MR
First Name:FAVIO
Middle Name:ALBERTO
Last Name:LEON
Suffix:JR
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N RENO ST APT 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4678
Mailing Address - Country:US
Mailing Address - Phone:213-858-8748
Mailing Address - Fax:
Practice Address - Street 1:2604 S. VERMONT AVE., #F
Practice Address - Street 2:WEST COAST DENTAL GROUP
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007
Practice Address - Country:US
Practice Address - Phone:323-731-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77346126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77346OtherRDA LICENSE