Provider Demographics
NPI:1013162502
Name:WADDELL, TRACY L (RDH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:WADDELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511
Mailing Address - Country:US
Mailing Address - Phone:757-953-8547
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511
Practice Address - Country:US
Practice Address - Phone:757-953-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402003311124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist