Provider Demographics
NPI:1568191922
Name:LEAVITT, JACOB GRANT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GRANT
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 4TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4455
Mailing Address - Country:US
Mailing Address - Phone:208-746-2646
Mailing Address - Fax:
Practice Address - Street 1:3326 4TH ST STE 1
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4455
Practice Address - Country:US
Practice Address - Phone:208-746-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-54181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice