Healthcare Provider Details

I. General information

NPI: 1124381298
Provider Name (Legal Business Name): TRACY MARIE KIRK D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N BEACH ST
HALTOM CITY TX
76137-2622
US

IV. Provider business mailing address

6300 N BEACH ST
HALTOM CITY TX
76137-2622
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 Code122300000X
TaxonomyDentist
License Number29655
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: