=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124103494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY MICHELLE EDWARDS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3320 S CHURCH ST CORRECT TIME PLAZA
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-9150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-584-7728
-----------------------------------------------------
Fax | 336-584-8730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3320 S CHURCH ST CORRECT TIME PLAZA
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-9150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-584-7728
-----------------------------------------------------
Fax | 336-584-8730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6626
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------