MEDICARE: TRACI R. FERNANDES, DDS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	41830	CA

General Provider Information

NPI Number	:	1225042120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRACI R. FERNANDES, DDS, INC

Provider Business Mailing Address
First Line	:	901 OAK PARK BLVD
Second Line	:	SUITE 203
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-3216
Country	:	US
Telephone Number	:	805-489-8232
Fax Number	:	805-489-8234

Provider Business Practice Location Address
First Line	:	901 OAK PARK BLVD
Second Line	:	SUITE 203
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-3216
Country	:	US
Telephone Number	:	805-489-8232
Fax Number	:	805-489-8234

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	TRACI R. FERNANDES
Credential	:	DDS, MS
Telephone Number	:	805-489-8232

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/22/2020

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