Healthcare Provider Details

I. General information

NPI: 1295714285
Provider Name (Legal Business Name): TRACEY NEARY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 N MARKET ST
NANTICOKE PA
18634-1411
US

IV. Provider business mailing address

14 SALEM DR
WILKES BARRE PA
18702-7323
US

V. Phone/Fax

Practice location:
  • Phone: 570-735-2315
  • Fax: 570-735-9171
Mailing address:
  • Phone: 570-655-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS028547L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: