Provider Demographics
NPI:1730214735
Name:TRACY E. DURHAM DDS PC
Entity type:Organization
Organization Name:TRACY E. DURHAM DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-748-4494
Mailing Address - Street 1:145 TRADERS WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-6005
Mailing Address - Country:US
Mailing Address - Phone:912-748-4494
Mailing Address - Fax:
Practice Address - Street 1:145 TRADERS WAY
Practice Address - Street 2:SUITE D
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6005
Practice Address - Country:US
Practice Address - Phone:912-748-4494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0115411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty