MEDICARE: MICHELLE MIGNON LECKLITNER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12009478	IN

General Provider Information

NPI Number	:	1295951754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MIGNON LECKLITNER DDS

Provider Business Mailing Address
First Line	:	2011 KOSSUTH STREET
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905
Country	:	US
Telephone Number	:	765-447-4726
Fax Number	:	765-447-7891

Provider Business Practice Location Address
First Line	:	2011 KOSSUTH STREET
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905
Country	:	US
Telephone Number	:	765-447-4726
Fax Number	:	765-447-7891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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