Basic Information
| Provider Information | |||||||||
| NPI: | 1578040135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGO | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1113 HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097551460 | ||||||||
| FaxNumber: | 2097546278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DDS102710 | CA | Y | Dental Providers | Dentist |
No ID Information.