Provider Demographics
NPI:1912452228
Name:RICCIO LEACH, ELENA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:
Last Name:RICCIO LEACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:RICCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3722 RIDGELINE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-2028
Mailing Address - Country:US
Mailing Address - Phone:210-850-9886
Mailing Address - Fax:
Practice Address - Street 1:1313 GUADALUPE ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5554
Practice Address - Country:US
Practice Address - Phone:210-212-3900
Practice Address - Fax:210-680-2601
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist