MEDICARE: DR. STEPHEN ROBERT LEITGEN DDS

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	122300000X	Dentist	9940	MN

General Provider Information

NPI Number	:	1063553881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN ROBERT LEITGEN DDS

Provider Business Mailing Address
First Line	:	7324 BUSH LAKE DR
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55438-1682
Country	:	US
Telephone Number	:	952-303-3672
Fax Number	:

Provider Business Practice Location Address
First Line	:	7324 BUSH LAKE DR
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55438-1682
Country	:	US
Telephone Number	:	952-303-3672
Fax Number	:

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

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/28/2007

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