Provider Demographics
NPI:1902864804
Name:SAPP, TRACY DIRK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DIRK
Last Name:SAPP
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 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-2700
Practice Address - Street 1:416 W CAMP ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1799
Practice Address - Country:US
Practice Address - Phone:765-483-4469
Practice Address - Fax:765-483-4495
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100186680AMedicaid