Provider Demographics
NPI:1881140499
Name:TRACY L. DELORM, D.D.S. PLLC
Entity type:Organization
Organization Name:TRACY L. DELORM, D.D.S. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DELORM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-334-4001
Mailing Address - Street 1:9514 4TH ST NE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-1937
Mailing Address - Country:US
Mailing Address - Phone:425-334-4001
Mailing Address - Fax:425-335-4003
Practice Address - Street 1:9514 4TH ST. NE UNIT 102
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:425-334-4001
Practice Address - Fax:425-335-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE9086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA501627465Medicaid