Provider Demographics
NPI:1093919417
Name:LEAVITT, BRYCE D (DMD, MD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:D
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 S GREEN VALLEY PKWY #15
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052
Mailing Address - Country:US
Mailing Address - Phone:702-685-3700
Mailing Address - Fax:702-685-3701
Practice Address - Street 1:670 S GREEN VALLEY PKWY #15
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052
Practice Address - Country:US
Practice Address - Phone:702-685-3700
Practice Address - Fax:702-685-3701
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12476204E00000X
NVSZ-1271223S0112X
NV62271223S0112X
MN55354204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN884127000Medicaid
WI33826800Medicaid
MNENROLLEDMedicaid
MN850000134Medicare PIN
MNENROLLEDMedicaid