MEDICARE: JACK TRACY MILLS

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	1223G0001X	General Practice Dentistry	9869	TX

General Provider Information

NPI Number	:	1245344381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK TRACY MILLS

Provider Business Mailing Address
First Line	:	5491 BREWER RD
Second Line	:
City	:	SEALY
State	:	TX
Zip	:	77474
Country	:	US
Telephone Number	:	979-885-3667
Fax Number	:	979-885-3305

Provider Business Practice Location Address
First Line	:	1011 HIGHWAY 6 SOUTH
Second Line	:	STE 300
City	:	HOUSTON
State	:	TX
Zip	:	77077
Country	:	US
Telephone Number	:	281-556-1606
Fax Number	:	281-556-1438

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

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	10/21/2009

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