Healthcare Provider Details

I. General information

NPI: 1245687821
Provider Name (Legal Business Name): LEAH LOEHNDORF MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 2ND ST S
SAINT CLOUD MN
56301-3704
US

IV. Provider business mailing address

13301 MAPLE KNOLL WAY APT 1705
MAPLE GROVE MN
55369-5006
US

V. Phone/Fax

Practice location:
  • Phone: 320-774-2556
  • Fax: 320-774-2559
Mailing address:
  • Phone: 414-651-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT54
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: