MEDICARE: MRS. KYRA J TRACY RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	2013010347	MO

General Provider Information

NPI Number	:	1003295460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KYRA J TRACY RDH

Provider Business Mailing Address
First Line	:	608 S. MISSOURI ST.
Second Line	:
City	:	WAVERLY
State	:	MO
Zip	:	64096
Country	:	US
Telephone Number	:	660-493-2262
Fax Number	:	660-493-2796

Provider Business Practice Location Address
First Line	:	608 S MISSOURI ST.
Second Line	:
City	:	WAVERLY
State	:	MO
Zip	:	64096
Country	:	US
Telephone Number	:	660-493-2262
Fax Number	:	660-493-2796

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	05/19/2015

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