Provider Demographics
NPI:1326145046
Name:BLOUNT, TRACY ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ELAINE
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:ELAINE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1014 FRANKLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1327
Mailing Address - Country:US
Mailing Address - Phone:616-452-0400
Mailing Address - Fax:616-243-3728
Practice Address - Street 1:1014 FRANKLIN ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1327
Practice Address - Country:US
Practice Address - Phone:616-452-0400
Practice Address - Fax:616-243-3728
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2759918Medicaid