1295951754 NPI number — MICHELLE MIGNON LECKLITNER DDS

Table of content: MICHELLE MIGNON LECKLITNER DDS (NPI 1295951754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295951754 NPI number — MICHELLE MIGNON LECKLITNER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LECKLITNER
Provider First Name:
MICHELLE
Provider Middle Name:
MIGNON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ASHCRAFT
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
MIGNON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1295951754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2011 KOSSUTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-447-4726
Provider Business Mailing Address Fax Number:
765-447-7891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2011 KOSSUTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-447-4726
Provider Business Practice Location Address Fax Number:
765-447-7891
Provider Enumeration Date:
04/17/2007

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: 122300000X , with the licence number:  12009478 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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