Basic Information
| Provider Information | |||||||||
| NPI: | 1003016536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN LEEUWEN | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6936 SOUTH 2475 EAST | ||||||||
| Address2: | 201 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841219999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019431612 | ||||||||
| FaxNumber: | 8019426008 | ||||||||
| Practice Location | |||||||||
| Address1: | 6936 SOUTH 2475 EAST | ||||||||
| Address2: | 201 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841215999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019431612 | ||||||||
| FaxNumber: | 8019426008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6610915 | UT | Y | Dental Providers | Dentist | General Practice |
No ID Information.