Healthcare Provider Details

I. General information

NPI: 1093919417
Provider Name (Legal Business Name): BRYCE D LEAVITT DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 S GREEN VALLEY PKWY #15
HENDERSON NV
89052
US

IV. Provider business mailing address

670 S GREEN VALLEY PKWY #15
HENDERSON NV
89052
US

V. Phone/Fax

Practice location:
  • Phone: 702-685-3700
  • Fax: 702-685-3701
Mailing address:
  • Phone: 702-685-3700
  • Fax: 702-685-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD12476
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberSZ-127
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6227
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number55354
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: