Healthcare Provider Details

I. General information

NPI: 1366580888
Provider Name (Legal Business Name): TRACY S BASS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 WHITTLE CIR
ASHBURN GA
31714-1918
US

IV. Provider business mailing address

462 RED OAK RD
TIFTON GA
31793-5333
US

V. Phone/Fax

Practice location:
  • Phone: 229-567-4316
  • Fax: 229-567-4316
Mailing address:
  • Phone: 229-567-4316
  • Fax: 229-567-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH005972
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: