MEDICARE: BRANDON DEE LEAVITT

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	39501	TX

General Provider Information

NPI Number	:	1891485298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON DEE LEAVITT

Provider Business Mailing Address
First Line	:	5800 N INTERSTATE 35 STE 205
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76207-1438
Country	:	US
Telephone Number	:	940-220-7833
Fax Number	:

Provider Business Practice Location Address
First Line	:	606 S COLORADO ST
Second Line	:
City	:	LOCKHART
State	:	TX
Zip	:	78644-3102
Country	:	US
Telephone Number	:	512-362-6648
Fax Number	:

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

Provider Enumeration Date	:	05/09/2023
Last Update Date	:	06/15/2023

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Directions to “ BRANDON DEE LEAVITT ” Practice Location

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