Provider Demographics
NPI:1336294008
Name:GRACE, DAVID LEE (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
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 1:2017 N GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2619
Mailing Address - Country:US
Mailing Address - Phone:479-442-9871
Mailing Address - Fax:479-444-0043
Practice Address - Street 1:2017 N GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2619
Practice Address - Country:US
Practice Address - Phone:479-442-9871
Practice Address - Fax:479-444-0043
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR23311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice