Healthcare Provider Details

I. General information

NPI: 1316970551
Provider Name (Legal Business Name): LEROY PLACE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 E DON TYLER AVE
DEWEY OK
74029-2315
US

IV. Provider business mailing address

417 E. DON TYLER AVE
DEWEY OK
74029-2315
US

V. Phone/Fax

Practice location:
  • Phone: 918-534-3170
  • Fax: 918-534-1522
Mailing address:
  • Phone: 918-534-3170
  • Fax: 918-534-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2719
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: