Provider Demographics
NPI:1295818995
Name:KRAMER, MITCHELL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:W
Last Name:KRAMER
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834
Mailing Address - Country:US
Mailing Address - Phone:405-258-2684
Mailing Address - Fax:405-258-5353
Practice Address - Street 1:1516 SOUTH IOWA
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834
Practice Address - Country:US
Practice Address - Phone:405-258-2684
Practice Address - Fax:405-258-5353
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
01307505OtherUNITED CONCORDIA
OK100120240AMedicaid