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General NPI Number Information
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NPI Number | 1629151188
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Entity Type | Organization
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Legal Business Name | EASTERN OKLAHOMA ORAL MAXILLOFACIAL SURGEONS
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 07/23/2018
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Provider Practice Location Address
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Address Line | 2950 S ELM PLACE, SUITE 340
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City | BROKEN ARROW
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State | OK
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Zip | 74012
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Country | US
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Telephone | 918-451-0944
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Fax |
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Provider Business Mailing Address
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Address Line | 4716 W URBANA ST
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City | BROKEN ARROW
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State | OK
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Zip | 74012-5997
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Country | US
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Telephone | 918-449-5800
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Fax | 918-455-8958
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Authorized Official
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Title or Position | OWNER / SURGEON
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Name | MR. VIC HILL TRAMMELL
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Credential |
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Telephone | 918-451-0944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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