Healthcare Provider Details

I. General information

NPI: 1629151188
Provider Name (Legal Business Name): EASTERN OKLAHOMA ORAL MAXILLOFACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 S ELM PLACE, SUITE 340
BROKEN ARROW OK
74012
US

IV. Provider business mailing address

4716 W URBANA ST
BROKEN ARROW OK
74012-5997
US

V. Phone/Fax

Practice location:
  • Phone: 918-451-0944
  • Fax:
Mailing address:
  • Phone: 918-449-5800
  • Fax: 918-455-8958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MR. VIC HILL TRAMMELL
Title or Position: OWNER / SURGEON
Credential:
Phone: 918-451-0944