Provider Demographics
NPI:1265756308
Name:VIC H. TRAMMELL DMD, PC
Entity type:Organization
Organization Name:VIC H. TRAMMELL DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-494-8634
Mailing Address - Street 1:2950 S ELM PL
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7877
Mailing Address - Country:US
Mailing Address - Phone:918-451-0944
Mailing Address - Fax:918-455-8598
Practice Address - Street 1:2950 S ELM PL
Practice Address - Street 2:SUITE 340
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7877
Practice Address - Country:US
Practice Address - Phone:918-451-0944
Practice Address - Fax:918-455-8598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100185040AMedicaid