Provider Demographics
NPI: | 1629151188 |
---|---|
Name: | EASTERN OKLAHOMA ORAL MAXILLOFACIAL SURGEONS |
Entity Type: | Organization |
Organization Name: | EASTERN OKLAHOMA ORAL MAXILLOFACIAL SURGEONS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER / SURGEON |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | VIC |
Authorized Official - Middle Name: | HILL |
Authorized Official - Last Name: | TRAMMELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 918-451-0944 |
Mailing Address - Street 1: | 4716 W URBANA ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BROKEN ARROW |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74012-5997 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 918-449-5800 |
Mailing Address - Fax: | 918-455-8958 |
Practice Address - Street 1: | 2950 S ELM PLACE, SUITE 340 |
Practice Address - Street 2: | |
Practice Address - City: | BROKEN ARROW |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74012 |
Practice Address - Country: | US |
Practice Address - Phone: | 918-451-0944 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-10-20 |
Last Update Date: | 2018-07-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Single Specialty |