Basic Information
| Provider Information | |||||||||
| NPI: | 1164669750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIDEMANN | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIFFIN | ||||||||
| OtherFirstName: | KRISTI | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7291 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042437291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778950 | ||||||||
| FaxNumber: | 2077778800 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 SECOND ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042106853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077553456 | ||||||||
| FaxNumber: | 2077553457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2009 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 51 024362 | NY | N | Dental Providers | Dental Hygienist | 124Q00000X | 6417 | TN | N | Dental Providers | Dental Hygienist | 124Q00000X | RDH2901 | ME | Y | Dental Providers | Dental Hygienist |
No ID Information.