Provider Demographics
NPI:1336144286
Name:LEIDTKE, BYRON T (DDS)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:T
Last Name:LEIDTKE
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 1:226 N. LIBERTY ST.
Mailing Address - Street 2:P.O. BOX 364
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015
Mailing Address - Country:US
Mailing Address - Phone:740-363-1343
Mailing Address - Fax:740-363-9424
Practice Address - Street 1:226 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1644
Practice Address - Country:US
Practice Address - Phone:740-363-1343
Practice Address - Fax:740-363-9424
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH122621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice