=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114053857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDODONTICS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 28TH ST
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-224-4455
-----------------------------------------------------
Fax | 515-224-4040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1450 28TH ST
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-224-4455
-----------------------------------------------------
Fax | 515-224-4040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL HENRY LEUCK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 515-224-4455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 05633
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------