Provider Demographics
NPI:1710350186
Name:BRACK, TAMMY LYNN
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:BRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1504 W ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1296
Mailing Address - Country:US
Mailing Address - Phone:509-949-0502
Mailing Address - Fax:
Practice Address - Street 1:1504 W ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1296
Practice Address - Country:US
Practice Address - Phone:509-949-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00006436124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADH00006436OtherRDH LICENSE NUMBER