Provider Demographics
NPI:1639242084
Name:MICHAEL VAN LEEUWEN DMD PC
Entity Type:Organization
Organization Name:MICHAEL VAN LEEUWEN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VAN LEEUWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-943-1612
Mailing Address - Street 1:6936 SOUTH 2475 EAST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-943-1612
Mailing Address - Fax:801-942-6008
Practice Address - Street 1:6936 SOUTH 2475 EAST
Practice Address - Street 2:SUITE 201
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-943-1612
Practice Address - Fax:801-942-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13807499221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty