Provider Demographics
NPI:1720171697
Name:DELORM, TRACY LYNN (DDS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:DELORM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9421 N DAVIES RD
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9444
Mailing Address - Country:US
Mailing Address - Phone:425-334-4001
Mailing Address - Fax:425-335-4003
Practice Address - Street 1:9421 N DAVIES RD
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9444
Practice Address - Country:US
Practice Address - Phone:425-334-4001
Practice Address - Fax:425-335-4003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA90861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUNITED CONCORDIAOther1434898
WA9086OtherLICENSE NUMBER
WA5041215Medicare ID - Type Unspecified