Healthcare Provider Details

I. General information

NPI: 1992249239
Provider Name (Legal Business Name): TRACY KIRK DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N. BEACH ST
FT WORTH TX
76137
US

IV. Provider business mailing address

6300 N. BEACH ST
HALTOM CITY TX
76137
US

V. Phone/Fax

Practice location:
  • Phone: 817-281-3100
  • Fax: 817-788-5984
Mailing address:
  • Phone: 817-281-3100
  • Fax: 817-788-5984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29655
License Number StateTX

VIII. Authorized Official

Name: MRS. JAMIE E GOMEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 817-281-3100