Provider Demographics
NPI:1669683173
Name:DURANT, TRACY L (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:DURANT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:LYNDELL
Other - Last Name:DURANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1125 N ANDERSON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-2776
Mailing Address - Country:US
Mailing Address - Phone:803-325-8178
Mailing Address - Fax:803-325-8179
Practice Address - Street 1:1125 N ANDERSON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-2776
Practice Address - Country:US
Practice Address - Phone:803-325-8178
Practice Address - Fax:803-325-8179
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3506122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9577Medicaid
SC710905114OtherEMPLOYEE I.D. NUMBER