Provider Demographics
NPI:1144849829
Name:VAN LEIR-MORALES, KATELYN NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:NICOLE
Last Name:VAN LEIR-MORALES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SURABIAN DENTAL CARE CENTER - SUITE 2500
Mailing Address - Street 2:290 N. WAYTE LANE
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3389
Practice Address - Country:US
Practice Address - Phone:800-492-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1066041223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program