MEDICARE: DR. TRACIE GAYLE MALLOY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5399	OK

General Provider Information

NPI Number	:	1386852150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACIE GAYLE MALLOY D.D.S.

Provider Business Mailing Address
First Line	:	1225 E 19TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74120-7418
Country	:	US
Telephone Number	:	918-582-3927
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 E 19TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74120-7418
Country	:	US
Telephone Number	:	918-582-3927
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/08/2007

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