MEDICARE: JOHN R. LEVERENZ DDS PC

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	261QD0000X	Dental Clinic/Center	13171	MI

General Provider Information

NPI Number	:	1902070311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN R. LEVERENZ DDS PC

Provider Business Mailing Address
First Line	:	24619 HARPER AVE
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1272
Country	:	US
Telephone Number	:	586-773-1010
Fax Number	:	586-773-6555

Provider Business Practice Location Address
First Line	:	24619 HARPER AVE
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1272
Country	:	US
Telephone Number	:	586-773-1010
Fax Number	:	586-773-6555

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN ROBERT LEVERENZ
Credential	:	DDS
Telephone Number	:	586-773-1010

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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