Healthcare Provider Details

I. General information

NPI: 1659438653
Provider Name (Legal Business Name): LEROY RICHARDSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NW 9TH ST
CHECOTAH OK
74426
US

IV. Provider business mailing address

100 NW 9TH ST PO BOX 328
CHECOTAH OK
74426
US

V. Phone/Fax

Practice location:
  • Phone: 918-473-3700
  • Fax: 918-473-3317
Mailing address:
  • Phone: 918-473-3700
  • Fax: 918-473-3317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11482
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5986
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: