Provider Demographics
NPI:1043707334
Name:DR. RONALD A. GRACE, DDS PLLC
Entity Type:Organization
Organization Name:DR. RONALD A. GRACE, DDS PLLC
Other - Org Name:GRACE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-595-3551
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:CABIN CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:25035-0040
Mailing Address - Country:US
Mailing Address - Phone:304-595-3551
Mailing Address - Fax:304-595-6822
Practice Address - Street 1:15081 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:CHELYAN
Practice Address - State:WV
Practice Address - Zip Code:25035
Practice Address - Country:US
Practice Address - Phone:304-595-3551
Practice Address - Fax:304-595-6822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137007000Medicaid