Provider Demographics
NPI:1073785002
Name:BLOCK, LEEANNE (BS)
Entity Type:Individual
Prefix:MRS
First Name:LEEANNE
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 EAST LOGAN
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270
Mailing Address - Country:US
Mailing Address - Phone:660-263-6643
Mailing Address - Fax:
Practice Address - Street 1:423 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2222
Practice Address - Country:US
Practice Address - Phone:660-263-6643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003614124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist