Basic Information
Provider Information
NPI: 1831346527
EntityType: 2
ReplacementNPI:  
OrganizationName: VAN LEEUWEN DENTAL, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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Mailing Information
Address1: 6936 SOUTH PROMENADE DR.
Address2: #201
City: SALT LAKE CITY
State: UT
PostalCode: 84121
CountryCode: US
TelephoneNumber: 8019431612
FaxNumber: 8019426008
Practice Location
Address1: 6936 PROMENADE DR
Address2: #201
City: SALT LAKE CITY
State: UT
PostalCode: 841213391
CountryCode: US
TelephoneNumber: 8019431612
FaxNumber: 8019426008
Other Information
ProviderEnumerationDate: 08/25/2008
LastUpdateDate: 08/25/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: VAN LEEUWEN
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: LEE
AuthorizedOfficialTitleorPosition: DENTIST/OWNER
AuthorizedOfficialTelephone: 8019431612
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: D.M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QD0000X138074UTY Ambulatory Health Care FacilitiesClinic/CenterDental

No ID Information.


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