Provider Demographics
NPI:1801388269
Name:LEICHTENBERGER, TRACY MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:LEICHTENBERGER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:SUPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:814-723-2333
Mailing Address - Fax:814-723-2355
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-2333
Practice Address - Fax:814-723-2355
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH012482L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034997720001Medicaid
PA1034997720002Medicaid