=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467061739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY M LEUTHNER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2020
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | US DENTAC HEALTH ACTIVITY FORT CAVAZOS 36000 SHOEMAKER LANE, SUITE 1051
-----------------------------------------------------
City | FORT HOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76544-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-287-2705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2D DENBN/NDC, PSC 20130 315 MCHUGH BLVD
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28542-0130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-451-2208
-----------------------------------------------------
Fax | 910-451-8479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11762591-9923
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DT-3143
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------