Provider Demographics
NPI:1538156849
Name:KIM, TRACY LEANN (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEANN
Last Name:KIM
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 1:705 INDIAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1750
Mailing Address - Country:US
Mailing Address - Phone:502-896-0826
Mailing Address - Fax:
Practice Address - Street 1:1000 BUCKNER CTR
Practice Address - Street 2:SUITE 3
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-7790
Practice Address - Country:US
Practice Address - Phone:502-222-8848
Practice Address - Fax:502-222-9319
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry