Healthcare Provider Details

I. General information

NPI: 1649669888
Provider Name (Legal Business Name): TRACY RENEE EVANS DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 WILLIAMS TER
ENCINITAS CA
92024-7280
US

IV. Provider business mailing address

2167 GRAND AVE
SAN DIEGO CA
92109-4606
US

V. Phone/Fax

Practice location:
  • Phone: 858-335-8722
  • Fax:
Mailing address:
  • Phone: 727-480-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number64262
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: