Provider Demographics
NPI:1700286655
Name:WHITLEY, TRACEY (DMD, MS)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:GERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 N STONEWALL AVE RM 524B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-8294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist