Provider Demographics
NPI:1316415524
Name:MONTOYA, TRACY (RDH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 BROAD WATER CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4337
Mailing Address - Country:US
Mailing Address - Phone:516-643-6056
Mailing Address - Fax:
Practice Address - Street 1:200 SAN SEBASTIAN VW
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-8695
Practice Address - Country:US
Practice Address - Phone:904-209-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH23696124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist