Healthcare Provider Details

I. General information

NPI: 1013930411
Provider Name (Legal Business Name): MICHAEL FREDRICK LEIFERT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 5TH AVE SUITE 1J.K.
NEW YORK NY
10011-8859
US

IV. Provider business mailing address

30 5TH AVE SUITE 1J.K.
NEW YORK NY
10011-8859
US

V. Phone/Fax

Practice location:
  • Phone: 212-533-7880
  • Fax: 212-533-0162
Mailing address:
  • Phone: 212-533-7880
  • Fax: 212-533-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050168
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: