Provider Demographics
NPI:1386852150
Name:MALLOY, TRACIE GAYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:GAYLE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-7418
Mailing Address - Country:US
Mailing Address - Phone:918-582-3927
Mailing Address - Fax:
Practice Address - Street 1:1225 E 19TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-7418
Practice Address - Country:US
Practice Address - Phone:918-582-3927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice