=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326030107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEE R. CENTRACCO DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5400 N GRAND BLVD STE 150
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-946-5198
-----------------------------------------------------
Fax | 405-946-9378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 N GRAND BLVD STE 150
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-946-5198
-----------------------------------------------------
Fax | 405-946-9378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5 3716
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------