Healthcare Provider Details

I. General information

NPI: 1831346527
Provider Name (Legal Business Name): VAN LEEUWEN DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6936 PROMENADE DR #201
SALT LAKE CITY UT
84121-3391
US

IV. Provider business mailing address

6936 SOUTH PROMENADE DR. #201
SALT LAKE CITY UT
84121
US

V. Phone/Fax

Practice location:
  • Phone: 801-943-1612
  • Fax: 801-942-6008
Mailing address:
  • Phone: 801-943-1612
  • Fax: 801-942-6008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number138074
License Number StateUT

VIII. Authorized Official

Name: DR. MICHAEL LEE VAN LEEUWEN
Title or Position: DENTIST/OWNER
Credential: D.M.D.
Phone: 801-943-1612