Provider Demographics
NPI:1740724681
Name:TRACY E. WALTERS DDS PA DBA SMILETASTIC
Entity type:Organization
Organization Name:TRACY E. WALTERS DDS PA DBA SMILETASTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:863-658-3276
Mailing Address - Street 1:4850 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2110
Mailing Address - Country:US
Mailing Address - Phone:863-658-3276
Mailing Address - Fax:863-658-3290
Practice Address - Street 1:4850 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2110
Practice Address - Country:US
Practice Address - Phone:863-658-3276
Practice Address - Fax:863-658-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN210531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty