Healthcare Provider Details

I. General information

NPI: 1942467915
Provider Name (Legal Business Name): LEROY PLACE D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
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 Code302F00000X
TaxonomyExclusive Provider Organization
License Number2719
License Number StateOK

VIII. Authorized Official

Name: GWEN PLACE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 918-534-3170