=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639487663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRACY H TAKENAKA, DDS,MSD,PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 STATION DR SUITE 180
-----------------------------------------------------
City | DUPONT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98327-9804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-915-7321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 STATION DR SUITE 180
-----------------------------------------------------
City | DUPONT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98327-9804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-915-7321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | TRACY HARUKO TAKENAKA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 360-742-9294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 60023910
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------