Healthcare Provider Details

I. General information

NPI: 1649196551
Provider Name (Legal Business Name): TRACY LEYSEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 2ND AVE N STE 2
WINDOM MN
56101-1766
US

IV. Provider business mailing address

1860 MURRAY AVE
SLAYTON MN
56172-2001
US

V. Phone/Fax

Practice location:
  • Phone: 507-831-3717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT196
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: