Provider Demographics
NPI:1003016536
Name:VAN LEEUWEN, ADAM RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:RICHARD
Last Name:VAN LEEUWEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6936 SOUTH 2475 EAST
Mailing Address - Street 2:201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-9999
Mailing Address - Country:US
Mailing Address - Phone:801-943-1612
Mailing Address - Fax:801-942-6008
Practice Address - Street 1:6936 SOUTH 2475 EAST
Practice Address - Street 2:201
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-5999
Practice Address - Country:US
Practice Address - Phone:801-943-1612
Practice Address - Fax:801-942-6008
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT66109151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice