Basic Information
| Provider Information | |||||||||
| NPI: | 1003295460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | KYRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 S. MISSOURI ST. | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604932262 | ||||||||
| FaxNumber: | 6604932796 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 S MISSOURI ST. | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604932262 | ||||||||
| FaxNumber: | 6604932796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2013010347 | MO | Y | Dental Providers | Dental Hygienist |
No ID Information.