Provider Demographics
NPI:1336383207
Name:PAYNE, TRACI MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MICHELLE
Last Name:PAYNE
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 1:300 W BROADWAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9078
Mailing Address - Country:US
Mailing Address - Phone:712-256-9151
Mailing Address - Fax:712-325-0288
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:SUITE 6
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9078
Practice Address - Country:US
Practice Address - Phone:712-256-9151
Practice Address - Fax:712-325-0288
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03217124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0188946Medicaid
1114906906OtherGROUP NPI