Provider Demographics
NPI:1811425895
Name:HILDEBRANDT, LEAH (DENTAL THERAPIST)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:HILDEBRANDT
Suffix:
Gender:F
Credentials:DENTAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:PO BOX 40
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636
Practice Address - Country:US
Practice Address - Phone:218-246-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND137011223G0001X
MND82821223G0001X
MN94991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1275797763OtherGOVERNMENT
MN1619949328OtherGOVERNMENT