Provider Demographics
NPI:1053779538
Name:TRACY L DAVIDIAN DDS PA
Entity type:Organization
Organization Name:TRACY L DAVIDIAN DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-782-9955
Mailing Address - Street 1:5904 SIX FORKS RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-3838
Mailing Address - Country:US
Mailing Address - Phone:919-782-9955
Mailing Address - Fax:
Practice Address - Street 1:5904 SIX FORKS RD
Practice Address - Street 2:SUITE 225
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3838
Practice Address - Country:US
Practice Address - Phone:919-782-9955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7149332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment