Provider Demographics
NPI:1649669888
Name:EVANS, TRACY RENEE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:RENEE
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4606
Mailing Address - Country:US
Mailing Address - Phone:727-480-9591
Mailing Address - Fax:
Practice Address - Street 1:3550 WILLIAMS TER
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7280
Practice Address - Country:US
Practice Address - Phone:858-335-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA642621223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice