Individual
DR. CASEY JON LEAVITT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
333 W. CEDAR, POCATELLO, ID 83201-5045
(208) 233-6900
(208) 233-6909
Mailing address
333 W. CEDAR, POCATELLO, ID 83201-5045
(208) 233-6900
(208) 233-6909
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D3630
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00016K505
BLUE CROSS BLUE SHIELD
ID
01
—
1531413
UNITED CONCORDIA
ID
Enumeration date
10/02/2006
Last updated
07/08/2007
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