Provider Demographics
NPI:1245848126
Name:LEBO, KAYLA AVIVA (DDS)
Entity type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:AVIVA
Last Name:LEBO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 SUTTER ST RM 2307
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4209
Mailing Address - Country:US
Mailing Address - Phone:415-724-6344
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST RM 2307
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4209
Practice Address - Country:US
Practice Address - Phone:415-724-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist