Provider Demographics
NPI:1093741704
Name:TEVEBAUGH, LESLIE ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANNE
Last Name:TEVEBAUGH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANNE
Other - Last Name:PRUETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1722 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801
Mailing Address - Country:US
Mailing Address - Phone:580-256-6816
Mailing Address - Fax:580-256-9839
Practice Address - Street 1:1722 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-256-6816
Practice Address - Fax:580-256-9839
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice