Provider Demographics
NPI:1013329770
Name:LEONG, KELLY KIMIKO (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KIMIKO
Last Name:LEONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 GEARY BLVD # 102
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3316
Mailing Address - Country:US
Mailing Address - Phone:707-340-3886
Mailing Address - Fax:
Practice Address - Street 1:341 GELLERT BLVD STE C
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2616
Practice Address - Country:US
Practice Address - Phone:650-994-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1004611223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty