Provider Demographics
NPI:1518954007
Name:BOLDRY, TRACY LYNN (DMD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BOLDRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5100 SW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2321
Mailing Address - Country:US
Mailing Address - Phone:785-273-8109
Mailing Address - Fax:785-273-4096
Practice Address - Street 1:5100 SW 28TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-2321
Practice Address - Country:US
Practice Address - Phone:785-273-8109
Practice Address - Fax:785-273-4096
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS6777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist