Provider Demographics
NPI:1295951754
Name:LECKLITNER, MICHELLE MIGNON (DDS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MIGNON
Last Name:LECKLITNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MIGNON
Other - Last Name:ASHCRAFT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2011 KOSSUTH STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905
Mailing Address - Country:US
Mailing Address - Phone:765-447-4726
Mailing Address - Fax:765-447-7891
Practice Address - Street 1:2011 KOSSUTH STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-447-4726
Practice Address - Fax:765-447-7891
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist