Provider Demographics
NPI:1962647578
Name:DR. ROBERT E. TRACY D.D.S., P.S.
Entity Type:Organization
Organization Name:DR. ROBERT E. TRACY D.D.S., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PS
Authorized Official - Phone:206-362-3833
Mailing Address - Street 1:11066 5TH AVE NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6156
Mailing Address - Country:US
Mailing Address - Phone:206-362-3833
Mailing Address - Fax:206-362-3834
Practice Address - Street 1:11066 5TH AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6156
Practice Address - Country:US
Practice Address - Phone:206-362-3833
Practice Address - Fax:206-362-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4990261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4990OtherLISCENCE
WA5002043OtherMEDICAID
WA970226OtherUNITED CONCORDIA PROVIDER ID
WA4990OtherLISCENCE