Provider Demographics
NPI:1396924833
Name:DEVAULT, TRACIE LOUISE (DDS)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LOUISE
Last Name:DEVAULT
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 1:1939 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:KEMAH
Mailing Address - State:TX
Mailing Address - Zip Code:77565-3122
Mailing Address - Country:US
Mailing Address - Phone:281-538-9300
Mailing Address - Fax:281-538-9031
Practice Address - Street 1:1939 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:KEMAH
Practice Address - State:TX
Practice Address - Zip Code:77565-3122
Practice Address - Country:US
Practice Address - Phone:281-538-9300
Practice Address - Fax:281-538-9031
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist