Provider Demographics
NPI:1952452211
Name:LECORN, DEMETRICK WAYNE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:DEMETRICK
Middle Name:WAYNE
Last Name:LECORN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 SW 22ND PL # 101
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7065
Mailing Address - Country:US
Mailing Address - Phone:352-291-9360
Mailing Address - Fax:352-291-9363
Practice Address - Street 1:2130 SW 22ND PL # 101
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7065
Practice Address - Country:US
Practice Address - Phone:352-291-9360
Practice Address - Fax:352-291-9363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN160081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics