Basic Information
| Provider Information | |||||||||
| NPI: | 1811155187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FILLER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | DAO | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1153 SOUTH KING ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082400250 | ||||||||
| FaxNumber: | 3232497565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1153 SOUTH KING ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082400250 | ||||||||
| FaxNumber: | 3232497565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 53511 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.