Provider Demographics
NPI:1265542096
Name:CARABALLO, LEEYA PAN (DDS)
Entity type:Individual
Prefix:MRS
First Name:LEEYA
Middle Name:PAN
Last Name:CARABALLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:LEEYA
Other - Middle Name:
Other - Last Name:PAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2445 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6003
Mailing Address - Country:US
Mailing Address - Phone:718-365-3344
Mailing Address - Fax:
Practice Address - Street 1:2445 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6003
Practice Address - Country:US
Practice Address - Phone:718-365-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893403Medicaid