MEDICARE: DR. ADAM RICHARD VAN LEEUWEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6610915	UT

General Provider Information

NPI Number	:	1003016536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAM RICHARD VAN LEEUWEN D.D.S.

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

Provider Business Practice Location Address
First Line	:	6936 SOUTH 2475 EAST
Second Line	:	201
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-5999
Country	:	US
Telephone Number	:	801-943-1612
Fax Number	:	801-942-6008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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