Provider Demographics
NPI:1295922946
Name:LEIPNITZ DENTAL CLINIC, SC
Entity type:Organization
Organization Name:LEIPNITZ DENTAL CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALERON
Authorized Official - Last Name:LEIPNITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-235-7371
Mailing Address - Street 1:2521 BROADWAY ST S
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3914
Mailing Address - Country:US
Mailing Address - Phone:715-235-7371
Mailing Address - Fax:715-235-7380
Practice Address - Street 1:2521 BROADWAY ST S
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3914
Practice Address - Country:US
Practice Address - Phone:715-235-7371
Practice Address - Fax:715-235-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5165-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33757000Medicaid