Provider Demographics
NPI:1255066379
Name:DE LEON, RYAN DRAKE NEPOMUCENO (DMD)
Entity type:Individual
Prefix:
First Name:RYAN DRAKE
Middle Name:NEPOMUCENO
Last Name:DE LEON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 GARNET CIR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8375
Mailing Address - Country:US
Mailing Address - Phone:707-315-2210
Mailing Address - Fax:
Practice Address - Street 1:10316 MASON AVE
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-3305
Practice Address - Country:US
Practice Address - Phone:818-493-1302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice