Provider Demographics
NPI:1285704510
Name:TRACY J. WATERS, DDS., PA
Entity type:Organization
Organization Name:TRACY J. WATERS, DDS., PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:919-620-6700
Mailing Address - Street 1:4210 N ROXBORO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1826
Mailing Address - Country:US
Mailing Address - Phone:919-620-6700
Mailing Address - Fax:919-620-7360
Practice Address - Street 1:4210 N ROXBORO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1826
Practice Address - Country:US
Practice Address - Phone:919-620-6700
Practice Address - Fax:919-620-7360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016JFMedicaid