Healthcare Provider Details

I. General information

NPI: 1588771703
Provider Name (Legal Business Name): TRACY R PATTERSON DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WALLIS CT
LEXINGTON MA
02421-5403
US

IV. Provider business mailing address

1 WALLIS CT
LEXINGTON MA
02421-5403
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-2625
  • Fax: 781-862-9169
Mailing address:
  • Phone: 781-862-2625
  • Fax: 781-862-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19576
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: