Provider Demographics
NPI:1538185376
Name:PECK, LEON ROBERT (DDS, PHD)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:ROBERT
Last Name:PECK
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 815
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3121
Mailing Address - Country:US
Mailing Address - Phone:310-657-6363
Mailing Address - Fax:310-652-5785
Practice Address - Street 1:8500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 815
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3121
Practice Address - Country:US
Practice Address - Phone:310-657-6363
Practice Address - Fax:310-652-5785
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383481223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB38348-01Medicaid
CAD38348Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAB38348-01Medicaid