Provider Demographics
NPI:1174934574
Name:DIERCKS, LEEANN (DDS)
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 19TH ST SE
Mailing Address - Street 2:PO BOX 330
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-3938
Mailing Address - Country:US
Mailing Address - Phone:605-886-2805
Mailing Address - Fax:
Practice Address - Street 1:20 19TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3938
Practice Address - Country:US
Practice Address - Phone:605-886-2805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1113122300000X
MND13356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist