Provider Demographics
NPI:1396110078
Name:DELEON, NINO CARLO
Entity type:Individual
Prefix:
First Name:NINO CARLO
Middle Name:
Last Name:DELEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MONUMENT AVE STE G
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1452
Mailing Address - Country:US
Mailing Address - Phone:804-282-4646
Mailing Address - Fax:
Practice Address - Street 1:5500 MONUMENT AVE STE G
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226
Practice Address - Country:US
Practice Address - Phone:804-282-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist