MEDICARE: MICHAEL VAN LEEUWEN DMD PC

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	1223G0001X	General Practice Dentistry	1380749922	UT

General Provider Information

NPI Number	:	1639242084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL VAN LEEUWEN DMD PC

Provider Business Mailing Address
First Line	:	6936 SOUTH 2475 EAST
Second Line	:	SUITE 201
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-943-1612
Fax Number	:	801-942-6008

Provider Business Practice Location Address
First Line	:	6936 SOUTH 2475 EAST
Second Line	:	SUITE 201
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-943-1612
Fax Number	:	801-942-6008

Authorized Official
Title or Position	:	PRESIDENT DENTIST
Name	:	MR. MICHAEL LEE VAN LEEUWEN
Credential	:	DMD
Telephone Number	:	801-943-1612

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	01/27/2014

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