MEDICARE: MRS. TRACI W SEXTON R.D.H.

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	124Q00000X	Dental Hygienist	0008610	FL

General Provider Information

NPI Number	:	1992893788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACI W SEXTON R.D.H.

Provider Business Mailing Address
First Line	:	3914 CALICO TRL
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-2278
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 A1A N
Second Line	:	SUITE 326
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-1823
Country	:	US
Telephone Number	:	904-273-8881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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