Provider Demographics
NPI:1508076332
Name:LEAVITT, SHARI TARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHARI
Middle Name:TARA
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 MARKET ST
Mailing Address - Street 2:BOX 1936
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3133
Mailing Address - Country:US
Mailing Address - Phone:215-662-1030
Mailing Address - Fax:215-662-1015
Practice Address - Street 1:3901 MARKET ST
Practice Address - Street 2:BOX 1936
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3133
Practice Address - Country:US
Practice Address - Phone:215-662-1030
Practice Address - Fax:215-662-1015
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS25799L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice