Provider Demographics
NPI:1376657825
Name:MOORE, TRACYE A (RDH, BS, MS)
Entity Type:Individual
Prefix:MS
First Name:TRACYE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:RDH, BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E PHIL ELLENA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1941
Mailing Address - Country:US
Mailing Address - Phone:215-438-6199
Mailing Address - Fax:215-443-6378
Practice Address - Street 1:NAVAL HEALTH CLINIC JOINT RESERVE BASE
Practice Address - Street 2:DENTAL DEPARTMENT BLDG 137
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090
Practice Address - Country:US
Practice Address - Phone:215-443-6380
Practice Address - Fax:215-443-6378
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH008983L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist