Provider Demographics
NPI:1356718548
Name:KHERADPOUR, TRACY TAT (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:TAT
Last Name:KHERADPOUR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:FELICIA
Other - Last Name:TAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 MONTECITO AVE, APT 22
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 MONTECITO AVE APT 22
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4334
Practice Address - Country:US
Practice Address - Phone:781-929-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA649851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice