Provider Demographics
NPI:1700969664
Name:BAFALOUKOS, LEONARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:BAFALOUKOS
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 1:3902 W. CAMELBACK RD.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-2897
Mailing Address - Country:US
Mailing Address - Phone:602-841-5473
Mailing Address - Fax:602-841-8640
Practice Address - Street 1:3902 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-5824
Practice Address - Country:US
Practice Address - Phone:602-841-5473
Practice Address - Fax:602-841-8640
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA803093OtherUNITED CONCORDIA
AZAZ0493590OtherBCBS OF AZ