Provider Demographics
NPI:1053407965
Name:BUTLER ROSS, TRACEY (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:BUTLER ROSS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3159
Mailing Address - Country:US
Mailing Address - Phone:859-291-1818
Mailing Address - Fax:
Practice Address - Street 1:1044 SCOTT ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3159
Practice Address - Country:US
Practice Address - Phone:859-291-1818
Practice Address - Fax:859-291-6441
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45002664Medicaid
OH2446642Medicaid
KY60001856Medicaid