Provider Demographics
NPI:1700964707
Name:LEAVITT, IRWIN MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRWIN
Middle Name:MARK
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 1:567 SOUTH BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4001
Mailing Address - Country:US
Mailing Address - Phone:818-365-9351
Mailing Address - Fax:818-365-6258
Practice Address - Street 1:567 SOUTH BRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4001
Practice Address - Country:US
Practice Address - Phone:818-365-9351
Practice Address - Fax:818-365-6258
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist