Provider Demographics
NPI:1124666573
Name:LEIVA, KATHERINE LYNN (RDH)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LYNN
Last Name:LEIVA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MRS
Other - First Name:KATHERINE
Other - Middle Name:LYNN
Other - Last Name:LEIVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:1791 DEMPSEY CIR
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-8019
Mailing Address - Country:US
Mailing Address - Phone:815-325-1114
Mailing Address - Fax:
Practice Address - Street 1:1791 DEMPSEY CIR
Practice Address - Street 2:
Practice Address - City:PINGREE GROVE
Practice Address - State:IL
Practice Address - Zip Code:60140-8019
Practice Address - Country:US
Practice Address - Phone:815-325-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020012552124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist