Provider Demographics
NPI:1902000656
Name:DR. LEONARD BAFALOUKOS D.D.S.
Entity Type:Organization
Organization Name:DR. LEONARD BAFALOUKOS D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAFALOUKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-841-5473
Mailing Address - Street 1:3902 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-5824
Mailing Address - Country:US
Mailing Address - Phone:602-841-5473
Mailing Address - Fax:602-841-8640
Practice Address - Street 1:3902 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-5824
Practice Address - Country:US
Practice Address - Phone:602-841-5473
Practice Address - Fax:602-841-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1523261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA803093OtherUNITED CONCORDIA
AZAZ0493590OtherBLUE CROSS BLUE SHIELD