Provider Demographics
NPI:1972342574
Name:RACZKOWSKI, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:RACZKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 NW 61ST TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4219
Mailing Address - Country:US
Mailing Address - Phone:405-642-5249
Mailing Address - Fax:
Practice Address - Street 1:4770 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3024
Practice Address - Country:US
Practice Address - Phone:918-215-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist