Provider Demographics
NPI:1154039345
Name:MOYA, TRACIE (RDH)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:MOYA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N MCCARTHY RD STE S
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9111
Mailing Address - Country:US
Mailing Address - Phone:920-731-7445
Mailing Address - Fax:
Practice Address - Street 1:5337 W GRANDE MARKET DRIVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-5491
Practice Address - Country:US
Practice Address - Phone:920-731-7445
Practice Address - Fax:920-882-2946
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7001063-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7001063-16Medicaid