Provider Demographics
NPI:1457304362
Name:BYLSMA-MULDER, LEANNE C (DDS)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:C
Last Name:BYLSMA-MULDER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1535
Mailing Address - Country:US
Mailing Address - Phone:712-722-2633
Mailing Address - Fax:712-722-2638
Practice Address - Street 1:159 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1535
Practice Address - Country:US
Practice Address - Phone:712-722-2633
Practice Address - Fax:712-722-2638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7596122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0091488Medicaid
IA0091488Medicaid