Healthcare Provider Details

I. General information

NPI: 1003295460
Provider Name (Legal Business Name): KYRA J TRACY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 S MISSOURI ST.
WAVERLY MO
64096
US

IV. Provider business mailing address

608 S. MISSOURI ST.
WAVERLY MO
64096
US

V. Phone/Fax

Practice location:
  • Phone: 660-493-2262
  • Fax: 660-493-2796
Mailing address:
  • Phone: 660-493-2262
  • Fax: 660-493-2796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2013010347
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: