Provider Demographics
NPI:1245687821
Name:LOEHNDORF, LEAH (MDT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:LOEHNDORF
Suffix:
Gender:F
Credentials:MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13301 MAPLE KNOLL WAY
Mailing Address - Street 2:APT 1705
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5006
Mailing Address - Country:US
Mailing Address - Phone:414-651-1000
Mailing Address - Fax:
Practice Address - Street 1:4128 2ND ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3704
Practice Address - Country:US
Practice Address - Phone:320-774-2556
Practice Address - Fax:320-774-2559
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT54125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist