Provider Demographics
NPI:1023543287
Name:SAND DOLLAR DENTAL, INC
Entity Type:Organization
Organization Name:SAND DOLLAR DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-712-2307
Mailing Address - Street 1:2631 HIDDEN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-6704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HOLLYWOOD BLVD SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5727
Practice Address - Country:US
Practice Address - Phone:850-712-2307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty