MEDICARE: DR. FREDERICK JAMES LEAVITT 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	1223G0001X	General Practice Dentistry	2901012134	MI

General Provider Information

NPI Number	:	1912948456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK JAMES LEAVITT DDS

Provider Business Mailing Address
First Line	:	1088 S BAILEY AVE
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9728
Country	:	US
Telephone Number	:	269-637-1306
Fax Number	:	269-637-8250

Provider Business Practice Location Address
First Line	:	1088 S BAILEY AVE
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9728
Country	:	US
Telephone Number	:	269-637-1306
Fax Number	:	269-637-8250

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/08/2007

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