Provider Demographics
NPI:1164697405
Name:DR. TRACY L. DURANT, INC.
Entity Type:Organization
Organization Name:DR. TRACY L. DURANT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNDELL
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:8093-325-8178
Mailing Address - Street 1:1125 ANDERSON RD N
Mailing Address - Street 2:SUTIE 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-2776
Mailing Address - Country:US
Mailing Address - Phone:803-325-8178
Mailing Address - Fax:
Practice Address - Street 1:1125 ANDERSON RD N
Practice Address - Street 2:SUTIE 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-2776
Practice Address - Country:US
Practice Address - Phone:803-325-8178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3506122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3506Medicaid