Provider Demographics
NPI:1194859702
Name:LEIDENHEIMER, STEPHEN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:LEIDENHEIMER
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 1:42707 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1054
Mailing Address - Country:US
Mailing Address - Phone:440-444-0379
Mailing Address - Fax:440-654-2778
Practice Address - Street 1:42707 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1054
Practice Address - Country:US
Practice Address - Phone:440-444-0379
Practice Address - Fax:440-654-2778
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300208761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2093907Medicaid