Provider Demographics
NPI:1093741183
Name:GOLDEN, TRACY G (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:G
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 WILSHIRE BLVD
Mailing Address - Street 2:1009
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3906
Mailing Address - Country:US
Mailing Address - Phone:310-209-7572
Mailing Address - Fax:310-209-7574
Practice Address - Street 1:10921 WILSHIRE BLVD
Practice Address - Street 2:1009
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3906
Practice Address - Country:US
Practice Address - Phone:310-209-7572
Practice Address - Fax:310-209-7574
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33208OtherLICENSE NUMBER