Provider Demographics
NPI:1205802303
Name:DELLAVECCHIA, TRACEY JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:JEAN
Last Name:DELLAVECCHIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:JEAN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MI
Mailing Address - Zip Code:49406-0109
Mailing Address - Country:US
Mailing Address - Phone:269-857-1431
Mailing Address - Fax:269-857-4089
Practice Address - Street 1:430 130TH AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-5100
Practice Address - Country:US
Practice Address - Phone:269-857-1431
Practice Address - Fax:269-857-4089
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist