Provider Demographics
NPI:1023099959
Name:BACON, TRACY LYNN (DDS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BACON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3108
Mailing Address - Country:US
Mailing Address - Phone:574-282-1390
Mailing Address - Fax:574-282-1394
Practice Address - Street 1:906 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3108
Practice Address - Country:US
Practice Address - Phone:574-282-1390
Practice Address - Fax:574-282-1394
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010041A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist