Provider Demographics
NPI:1659438653
Name:RICHARDSON, LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:RICHARDSON
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 1:100 NW 9TH ST
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426
Mailing Address - Country:US
Mailing Address - Phone:918-473-3700
Mailing Address - Fax:918-473-3317
Practice Address - Street 1:100 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426
Practice Address - Country:US
Practice Address - Phone:918-473-3700
Practice Address - Fax:918-473-3317
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11482122300000X
OK5986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist