Basic Information
Provider Information
NPI: 1922210442
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEITER
FirstName: TRENA
MiddleName: MAE
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 295 SE 191 RD
Address2:  
City: WARRENSBURG
State: MO
PostalCode: 64093
CountryCode: US
TelephoneNumber: 8168637783
FaxNumber:  
Practice Location
Address1: 3801 BLUE PARKWAY
Address2:  
City: KANSAS CITY
State: MO
PostalCode: 64130
CountryCode: US
TelephoneNumber: 8169235800
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/04/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X2007009361MOY Dental ProvidersDentist 

No ID Information.


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