Provider Demographics
NPI:1881751584
Name:DOUGLAS, TRACEY LAMAR (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LAMAR
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WATERFORD SQ
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6856
Mailing Address - Country:US
Mailing Address - Phone:601-856-3182
Mailing Address - Fax:601-856-9120
Practice Address - Street 1:204 WATERFORD SQ
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6856
Practice Address - Country:US
Practice Address - Phone:601-856-3182
Practice Address - Fax:601-856-9120
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3035-981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice