Healthcare Provider Details

I. General information

NPI: 1174588248
Provider Name (Legal Business Name): LEIGH VONWALD DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 442 HEIDELBERG DENTAL ACTIVITY CREDENTIALS OFFICE
APO AE
09042
US

IV. Provider business mailing address

CMR 442 HEIDELBERG DENTAL ACTIVITY CREDENTIALS OFFICE
APO AE
09042
US

V. Phone/Fax

Practice location:
  • Phone: 622-117-2728
  • Fax:
Mailing address:
  • Phone: 622-117-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8388
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: