Provider Demographics
NPI:1457978520
Name:LEAVITT, BRENNAN MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENNAN
Middle Name:MICHAEL
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151487 FERN LN
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5108
Mailing Address - Country:US
Mailing Address - Phone:208-989-7994
Mailing Address - Fax:
Practice Address - Street 1:2201 DIVISION ST # B
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3662
Practice Address - Country:US
Practice Address - Phone:715-341-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist