Provider Demographics
NPI:1811106677
Name:PAULSEN, TRACI (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:
Last Name:PAULSEN
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 1:923 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1330
Mailing Address - Country:US
Mailing Address - Phone:563-659-9500
Mailing Address - Fax:
Practice Address - Street 1:923 6TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1330
Practice Address - Country:US
Practice Address - Phone:563-659-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0264440Medicaid