1407901457 NPI number — DR TRACEY BUTLER ROSS, DMD, PLLC

Table of content: (NPI 1407901457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407901457 NPI number — DR TRACEY BUTLER ROSS, DMD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR TRACEY BUTLER ROSS, DMD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR TRACEY BUTLER ROSS, DMD, PLLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407901457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1044 SCOTT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41011-3159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-291-1818
Provider Business Mailing Address Fax Number:
859-291-6441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1044 SCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41011-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-291-1818
Provider Business Practice Location Address Fax Number:
859-291-6441
Provider Enumeration Date:
01/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BUTLER ROSS
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-291-1818

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6627 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2446642 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45002664 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60001856 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".