Provider Demographics
NPI:1144567504
Name:TRACY H TAKENAKA DDS MSD PS
Entity Type:Organization
Organization Name:TRACY H TAKENAKA DDS MSD PS
Other - Org Name:CHILDREN'S DENTISTRY OF DUPONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAKENAKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-964-0150
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:253-964-9830
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:253-964-9830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60023910261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental