=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730214735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRACY E. DURHAM DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 TRADERS WAY SUITE D
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-748-4494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 TRADERS WAY SUITE D
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-748-4494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TRACY ELLEN DURHAM
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 912-748-4494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN011541
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------