MEDICARE: DR. LEON DOUGLAS BRAGG SR. D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	3897	OK

General Provider Information

NPI Number	:	1639186729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEON DOUGLAS BRAGG SR. D.D.S.

Provider Business Mailing Address
First Line	:	1321 NE 54TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-6611
Country	:	US
Telephone Number	:	405-427-5309
Fax Number	:	405-530-7121

Provider Business Practice Location Address
First Line	:	1321 NE 54TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-6611
Country	:	US
Telephone Number	:	405-427-5309
Fax Number	:	405-530-7121

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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