Provider Demographics
NPI:1770318289
Name:LEONG, RYAN MACKENZIE (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MACKENZIE
Last Name:LEONG
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 1:609 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-2904
Mailing Address - Country:US
Mailing Address - Phone:415-816-7066
Mailing Address - Fax:
Practice Address - Street 1:420 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-342-3597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1106681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice