Provider Demographics
NPI:1396947693
Name:DEBERARDINIS, LEAH T
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:T
Last Name:DEBERARDINIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WALLENBERG WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4786
Mailing Address - Country:US
Mailing Address - Phone:707-799-7344
Mailing Address - Fax:707-763-3141
Practice Address - Street 1:511 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:707-763-2654
Practice Address - Fax:707-763-3141
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA515231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice