Provider Demographics
NPI:1497962146
Name:TRACY M. EDWARDS, DDS, PA
Entity Type:Organization
Organization Name:TRACY M. EDWARDS, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-584-7728
Mailing Address - Street 1:3320 S CHURCH ST
Mailing Address - Street 2:CORRECT TIME PLAZA
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9150
Mailing Address - Country:US
Mailing Address - Phone:336-584-7728
Mailing Address - Fax:336-584-8730
Practice Address - Street 1:3320 S CHURCH ST
Practice Address - Street 2:CORRECT TIME PLAZA
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9150
Practice Address - Country:US
Practice Address - Phone:336-584-7728
Practice Address - Fax:336-584-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty