Provider Demographics
NPI:1366580888
Name:BASS, TRACY S (RDH)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:S
Last Name:BASS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 RED OAK RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-5333
Mailing Address - Country:US
Mailing Address - Phone:229-567-4316
Mailing Address - Fax:229-567-4316
Practice Address - Street 1:274 WHITTLE CIR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-1918
Practice Address - Country:US
Practice Address - Phone:229-567-4316
Practice Address - Fax:229-567-4316
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH005972124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist