Provider Demographics
NPI:1790132249
Name:BETHA, TRACY J (RDHAP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:BETHA
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 MOUND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2846
Mailing Address - Country:US
Mailing Address - Phone:714-745-4989
Mailing Address - Fax:
Practice Address - Street 1:5454 MOUND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2846
Practice Address - Country:US
Practice Address - Phone:714-745-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-14
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP614124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist