Provider Demographics
NPI:1619610847
Name:FERNANDES, TRACI RACHELLE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:RACHELLE
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:TRACI
Other - Middle Name:RACHELLE
Other - Last Name:FERNANDES HENRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:901 OAK PARK BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3410
Mailing Address - Country:US
Mailing Address - Phone:805-489-8232
Mailing Address - Fax:805-489-8234
Practice Address - Street 1:901 OAK PARK BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3410
Practice Address - Country:US
Practice Address - Phone:805-489-8232
Practice Address - Fax:805-489-8234
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA418301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225042120OtherNPI 2