Provider Demographics
NPI:1104397868
Name:MATTHEW D GRACE DDS, PLLC
Entity Type:Organization
Organization Name:MATTHEW D GRACE DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-316-9419
Mailing Address - Street 1:353 VZCR 1519
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-5744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5621 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4348
Practice Address - Country:US
Practice Address - Phone:903-630-6313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental