Provider Demographics
NPI:1548519341
Name:DEPERALTA, TRACY (DMD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DEPERALTA
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:SCHOOL OF DENTAL MEDICINE UNIVERSITY OF COLORADO
Mailing Address - Street 2:13065 EAST 17TH AVENUE
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80045-1078
Mailing Address - Country:US
Mailing Address - Phone:303-724-9540
Mailing Address - Fax:
Practice Address - Street 1:13065 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:303-724-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010208131223G0001X
CODEN.00204232122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice