Provider Demographics
NPI:1073853586
Name:TRACY, LON ROLAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:LON
Middle Name:ROLAND
Last Name:TRACY
Suffix:
Gender:M
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:P.O. BOX 549
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701
Mailing Address - Country:US
Mailing Address - Phone:816-380-6000
Mailing Address - Fax:816-380-6000
Practice Address - Street 1:300 S. INDEPENDENCE STREET
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701
Practice Address - Country:US
Practice Address - Phone:816-380-6000
Practice Address - Fax:816-380-6000
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014713122300000X
MO147131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist