Provider Demographics
NPI:1619384047
Name:COBB, TRACEY RENAE (DDS)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENAE
Last Name:COBB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22266 CIVIC CENTER DR
Mailing Address - Street 2:APT. 212
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2622
Mailing Address - Country:US
Mailing Address - Phone:734-890-1222
Mailing Address - Fax:
Practice Address - Street 1:25225 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1462
Practice Address - Country:US
Practice Address - Phone:313-541-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010213651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice