Provider Demographics
NPI:1548340656
Name:KITTRELL, TRACY M (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:M
Last Name:KITTRELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-4410
Mailing Address - Country:US
Mailing Address - Phone:319-338-3023
Mailing Address - Fax:319-338-2284
Practice Address - Street 1:1421 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-4410
Practice Address - Country:US
Practice Address - Phone:319-338-3023
Practice Address - Fax:319-338-2284
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7074122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0033381Medicaid