=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669367652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNICCA ANN LEIER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2025
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1371 7TH ST W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-4297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-359-9889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18785 160TH AVE NW
-----------------------------------------------------
City | THIEF RIVER FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56701-8834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-688-2059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D15297
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------