Healthcare Provider Details

I. General information

NPI: 1821866682
Provider Name (Legal Business Name): LEAVITT ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BENCH RD STE A
POCATELLO ID
83201-5084
US

IV. Provider business mailing address

1455 BENCH RD STE A
POCATELLO ID
83201-5084
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-3330
  • Fax:
Mailing address:
  • Phone: 208-237-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TYLER LEAVITT
Title or Position: OWNER/DENTIST
Credential: DDS, MSD
Phone: 208-240-5219