1003016536 NPI number — DR. ADAM RICHARD VAN LEEUWEN D.D.S.

Table of content: DR. ADAM RICHARD VAN LEEUWEN D.D.S. (NPI 1003016536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003016536 NPI number — DR. ADAM RICHARD VAN LEEUWEN D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN LEEUWEN
Provider First Name:
ADAM
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003016536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6936 SOUTH 2475 EAST
Provider Second Line Business Mailing Address:
201
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84121-9999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-943-1612
Provider Business Mailing Address Fax Number:
801-942-6008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6936 SOUTH 2475 EAST
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84121-5999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-943-1612
Provider Business Practice Location Address Fax Number:
801-942-6008
Provider Enumeration Date:
07/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6610915 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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