Provider Demographics
NPI:1427162577
Name:LEMBKE, GRADY LABAR (DDS)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:LABAR
Last Name:LEMBKE
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 1:200 N SOONER RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7153
Mailing Address - Country:US
Mailing Address - Phone:405-330-6020
Mailing Address - Fax:405-341-0557
Practice Address - Street 1:200 N SOONER RD BLDG B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7153
Practice Address - Country:US
Practice Address - Phone:405-330-6020
Practice Address - Fax:405-341-0557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
875019OtherUNITED CONCORDIA
OK#5432OtherOKLAHOMA LICENSE #
274647298OtherTIN