Healthcare Provider Details

I. General information

NPI: 1831314830
Provider Name (Legal Business Name): TRACEY LYNN BRENNAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 WARWICK AVE
WARWICK RI
02888-2670
US

IV. Provider business mailing address

48 TEA HOUSE LN
WARWICK RI
02889-6420
US

V. Phone/Fax

Practice location:
  • Phone: 401-785-2111
  • Fax:
Mailing address:
  • Phone: 401-821-6500
  • Fax: 401-823-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN2603
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: