Provider Demographics
NPI:1326030107
Name:CENTRACCO, LEE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:R
Last Name:CENTRACCO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 N GRAND BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5692
Mailing Address - Country:US
Mailing Address - Phone:405-946-5198
Mailing Address - Fax:405-946-9378
Practice Address - Street 1:5400 N GRAND BLVD
Practice Address - Street 2:STE 150
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5692
Practice Address - Country:US
Practice Address - Phone:405-946-5198
Practice Address - Fax:405-946-9378
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5 37161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice