Provider Demographics
NPI:1417671140
Name:CRIST, TRACY JANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JANE
Last Name:CRIST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:JANE
Other - Last Name:CRIST-REBUYACO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:11418 VIA RANCHO SAN DIEGO UNIT 66
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-5232
Mailing Address - Country:US
Mailing Address - Phone:858-319-8414
Mailing Address - Fax:
Practice Address - Street 1:11418 VIA RANCHO SAN DIEGO UNIT 66
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-5232
Practice Address - Country:US
Practice Address - Phone:858-319-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1081571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice