Provider Demographics
NPI:1346304250
Name:VESTAL, TRACIE LEIGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:LEIGH
Last Name:VESTAL
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 1:500 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-9411
Mailing Address - Country:US
Mailing Address - Phone:910-862-4078
Mailing Address - Fax:910-862-4078
Practice Address - Street 1:500 W BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9411
Practice Address - Country:US
Practice Address - Phone:910-862-4078
Practice Address - Fax:910-862-4078
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC871334OtherUNITED CONCORDIA
NC902-ECOtherBCBS ID#
NC01-0570076OtherFEDERAL TAX ID #
NC7200OtherSTATE DENTAL LICENSE #
NC89902ECMedicaid
NC89902ECMedicaid