1205802303 NPI number — DR. TRACEY JEAN DELLAVECCHIA D.D.S.

Table of content: DR. TRACEY JEAN DELLAVECCHIA D.D.S. (NPI 1205802303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205802303 NPI number — DR. TRACEY JEAN DELLAVECCHIA D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELLAVECCHIA
Provider First Name:
TRACEY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
TRACEY
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205802303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49406-0109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-857-1431
Provider Business Mailing Address Fax Number:
269-857-4089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 130TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49406-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-857-1431
Provider Business Practice Location Address Fax Number:
269-857-4089
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2901018649 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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