Provider Demographics
NPI:1447305156
Name:PROVENGHI, TRACY LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:PROVENGHI
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 1:7400 VISCOUNT BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-4828
Mailing Address - Country:US
Mailing Address - Phone:915-772-4740
Mailing Address - Fax:915-772-4853
Practice Address - Street 1:7400 VISCOUNT BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-4851
Practice Address - Country:US
Practice Address - Phone:915-772-4740
Practice Address - Fax:915-772-4853
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX164561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice