Healthcare Provider Details

I. General information

NPI: 1639186729
Provider Name (Legal Business Name): LEON DOUGLAS BRAGG SR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 NE 54TH ST
OKLAHOMA CITY OK
73111-6611
US

IV. Provider business mailing address

1321 NE 54TH ST
OKLAHOMA CITY OK
73111-6611
US

V. Phone/Fax

Practice location:
  • Phone: 405-427-5309
  • Fax: 405-530-7121
Mailing address:
  • Phone: 405-427-5309
  • Fax: 405-530-7121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number3897
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: