Provider Demographics
NPI:1275547101
Name:SULLIVAN, TRACY C (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:C
Last Name:SULLIVAN
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 1:1880 POTTERY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2518
Mailing Address - Country:US
Mailing Address - Phone:360-895-4321
Mailing Address - Fax:360-895-4326
Practice Address - Street 1:1880 POTTERY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2518
Practice Address - Country:US
Practice Address - Phone:360-895-4321
Practice Address - Fax:360-895-4326
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000086421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice