Provider Demographics
NPI:1396735411
Name:DE LEON, JOSE RAFAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAFAEL
Last Name:DE LEON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4404
Mailing Address - Country:US
Mailing Address - Phone:516-561-9459
Mailing Address - Fax:
Practice Address - Street 1:143 ESSEX ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2336
Practice Address - Country:US
Practice Address - Phone:212-228-2999
Practice Address - Fax:212-228-3323
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0460961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01588090Medicaid