=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376959304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH KANNER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2014
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 21ST AVE
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-3091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-257-8224
-----------------------------------------------------
Fax | 772-213-3157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1545 9TH ST SW
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32962-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-257-8224
-----------------------------------------------------
Fax | 772-213-3157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN22058
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------