Provider Demographics
NPI:1831314830
Name:BRENNAN, TRACEY LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNN
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 TEA HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-6420
Mailing Address - Country:US
Mailing Address - Phone:401-821-6500
Mailing Address - Fax:401-823-8270
Practice Address - Street 1:708 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-2670
Practice Address - Country:US
Practice Address - Phone:401-785-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN26031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice