Provider Demographics
NPI:1225042120
Name:TRACI R. FERNANDES, DDS, INC
Entity Type:Organization
Organization Name:TRACI R. FERNANDES, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERNANDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:805-489-8232
Mailing Address - Street 1:901 OAK PARK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3216
Mailing Address - Country:US
Mailing Address - Phone:805-489-8232
Mailing Address - Fax:805-489-8234
Practice Address - Street 1:901 OAK PARK BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3216
Practice Address - Country:US
Practice Address - Phone:805-489-8232
Practice Address - Fax:805-489-8234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA418301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty