Provider Demographics
NPI:1952495491
Name:LEAVITT, CASEY JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:JON
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W. CEDAR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5045
Mailing Address - Country:US
Mailing Address - Phone:208-233-6900
Mailing Address - Fax:208-233-6909
Practice Address - Street 1:333 W. CEDAR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5045
Practice Address - Country:US
Practice Address - Phone:208-233-6900
Practice Address - Fax:208-233-6909
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00016K505OtherBLUE CROSS BLUE SHIELD
ID1531413OtherUNITED CONCORDIA