Provider Demographics
NPI:1164551115
Name:GRACE, PETER GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:GORDON
Last Name:GRACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-789-7922
Mailing Address - Fax:315-789-0078
Practice Address - Street 1:140 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-789-7922
Practice Address - Fax:315-789-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0524581223G0001X
NYNY0524581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice