Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 6227 | NV |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | SZ-127 | NV |
N | 204E00000X | Oral & Maxillofacial Surgeon | 55354 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | D12476 | MN |
NPI | 1093919417 |
---|---|
Provider Name | Bryce D Leavitt |
First Address | Henderson, NV 89052 |
Second Address | Henderson, NV 89052 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2007 |
Last Update Date | 19/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33826800 | (05) | WI |
884127000 | (05) | MN |
ENROLLED | (05) | MN |