Provider Demographics
NPI:1871681494
Name:WATERS, TRACY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:J
Last Name:WATERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 N. ROXBORO RD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704
Mailing Address - Country:US
Mailing Address - Phone:919-620-6700
Mailing Address - Fax:919-620-7360
Practice Address - Street 1:4210 N. ROXBORO RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704
Practice Address - Country:US
Practice Address - Phone:919-620-6700
Practice Address - Fax:919-620-7360
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016JFMedicaid