Provider Demographics
NPI:1063553881
Name:LEITGEN, STEPHEN ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:LEITGEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 BUSH LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1682
Mailing Address - Country:US
Mailing Address - Phone:952-303-3672
Mailing Address - Fax:
Practice Address - Street 1:7324 BUSH LAKE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1682
Practice Address - Country:US
Practice Address - Phone:952-303-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist