Provider Demographics
NPI:1356946370
Name:SANFILIPPO, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SANFILIPPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PRINCE ANTHONY LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7163
Mailing Address - Country:US
Mailing Address - Phone:386-569-9824
Mailing Address - Fax:
Practice Address - Street 1:250 PALM COAST PKWY NE UNIT 606
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8225
Practice Address - Country:US
Practice Address - Phone:386-446-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11668124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist