1912046871 NPI number — LEON D. ROISMAN, D.M.D., INC.

Table of content: (NPI 1912046871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912046871 NPI number — LEON D. ROISMAN, D.M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEON D. ROISMAN, D.M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL PLUS - A DENTAL GROUP OF LEON D. ROISMAN, D.M.D., INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912046871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 S LAKE AVE
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91101-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-795-6855
Provider Business Mailing Address Fax Number:
626-432-4260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S LAKE AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91101-3540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-795-6855
Provider Business Practice Location Address Fax Number:
626-432-4260
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROISMAN
Authorized Official First Name:
LEON
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
626-432-4242

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: B19960-01 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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