Provider Demographics
NPI:1447602602
Name:JOSHUA M LEAVITT DMD MS LLC
Entity Type:Organization
Organization Name:JOSHUA M LEAVITT DMD MS LLC
Other - Org Name:PEDIATRIC DENTISTRY OF CENTRAL OHIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:702-325-5268
Mailing Address - Street 1:1600 CROSS CREEKS BLVD
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-8189
Mailing Address - Country:US
Mailing Address - Phone:614-863-8500
Mailing Address - Fax:614-863-0874
Practice Address - Street 1:1600 CROSS CREEKS BLVD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8189
Practice Address - Country:US
Practice Address - Phone:614-863-8500
Practice Address - Fax:614-863-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0243551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121571Medicaid