Healthcare Provider Details

I. General information

NPI: 1902307911
Provider Name (Legal Business Name): TYLER LEAVITT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2018
Last Update Date: 02/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 HIGHWAY K
O FALLON MO
63368-8696
US

IV. Provider business mailing address

1200 E LINDEN AVE
SAINT LOUIS MO
63117-1315
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-7552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2018002229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: