Provider Demographics
NPI:1134784242
Name:KELSEY, TRACY LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:KELSEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 IRONWORKS AVE APT 264
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2070
Mailing Address - Country:US
Mailing Address - Phone:574-226-5700
Mailing Address - Fax:
Practice Address - Street 1:1802 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6463
Practice Address - Country:US
Practice Address - Phone:574-533-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013468A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice