Provider Demographics
NPI:1003295460
Name:TRACY, KYRA J (RDH)
Entity type:Individual
Prefix:MRS
First Name:KYRA
Middle Name:J
Last Name:TRACY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 S. MISSOURI ST.
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MO
Mailing Address - Zip Code:64096
Mailing Address - Country:US
Mailing Address - Phone:660-493-2262
Mailing Address - Fax:660-493-2796
Practice Address - Street 1:608 S MISSOURI ST.
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:MO
Practice Address - Zip Code:64096
Practice Address - Country:US
Practice Address - Phone:660-493-2262
Practice Address - Fax:660-493-2796
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013010347124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist