Provider Demographics
NPI:1477694628
Name:SISE, TRACY (COSA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:SISE
Suffix:
Gender:F
Credentials:COSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 COFFEE RD STE D
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4229
Mailing Address - Country:US
Mailing Address - Phone:209-522-5238
Mailing Address - Fax:209-522-4703
Practice Address - Street 1:1213 COFFEE RD STE D
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4229
Practice Address - Country:US
Practice Address - Phone:209-522-5238
Practice Address - Fax:209-522-4703
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant