Provider Demographics
NPI:1477728442
Name:TRACEY, BRIAN J (CDT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:J
Last Name:TRACEY
Suffix:
Gender:M
Credentials:CDT
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Mailing Address - Street 1:6 CALLE MEDICO
Mailing Address - Street 2:SUITE #5
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-982-4119
Mailing Address - Fax:505-982-0015
Practice Address - Street 1:6 CALLE MEDICO
Practice Address - Street 2:SUITE #5
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-982-4119
Practice Address - Fax:505-982-0015
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician