Basic Information
| Provider Information | |||||||||
| NPI: | 1639242084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL VAN LEEUWEN DMD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6936 SOUTH 2475 EAST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019431612 | ||||||||
| FaxNumber: | 8019426008 | ||||||||
| Practice Location | |||||||||
| Address1: | 6936 SOUTH 2475 EAST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019431612 | ||||||||
| FaxNumber: | 8019426008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | VAN LEEUWEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 8019431612 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1380749922 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.