Provider Demographics
NPI:1386772986
Name:DAVIES, TRACY (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:DAVIES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120
Mailing Address - Country:US
Mailing Address - Phone:262-642-5695
Mailing Address - Fax:262-642-5395
Practice Address - Street 1:2481 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120
Practice Address - Country:US
Practice Address - Phone:262-642-5695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33781300Medicaid
391449280018OtherBLUE CROSS