Provider Demographics
NPI:1679698864
Name:PETRY, TRACY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:PETRY
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 1:2493 S BRAESWOOD BLVD # C
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4332
Mailing Address - Country:US
Mailing Address - Phone:713-218-0500
Mailing Address - Fax:
Practice Address - Street 1:2493 S BRAESWOOD BLVD # C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4332
Practice Address - Country:US
Practice Address - Phone:713-218-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice