Provider Demographics
NPI:1124005525
Name:TAKENAKA, TRACY H (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:H
Last Name:TAKENAKA
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 1:1200 STATION DR STE 180
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-9804
Mailing Address - Country:US
Mailing Address - Phone:253-964-0150
Mailing Address - Fax:
Practice Address - Street 1:1200 STATION DR STE 180
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-9804
Practice Address - Country:US
Practice Address - Phone:253-964-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051468-11223G0001X
WADE600239101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice