MEDICARE: TRACIE MOYA 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	7001063-16	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154039345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE MOYA RDH

Provider Business Mailing Address
First Line	:	119 N MCCARTHY RD STE S
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-9111
Country	:	US
Telephone Number	:	920-731-7445
Fax Number	:

Provider Business Practice Location Address
First Line	:	5337 W GRANDE MARKET DRIVE
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-5491
Country	:	US
Telephone Number	:	920-731-7445
Fax Number	:	920-882-2946

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

Provider Enumeration Date	:	11/07/2022
Last Update Date	:	11/08/2022

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Directions to “ TRACIE MOYA RDH” Practice Location

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