Provider Demographics
NPI:1558920298
Name:GRACE JOTIKA DMD PC
Entity Type:Organization
Organization Name:GRACE JOTIKA DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUPAIPORN
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:JOTIKABHUKKANA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-304-5019
Mailing Address - Street 1:0 GOVERNORS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:0 GOVERNORS AVE STE 1
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3035
Practice Address - Country:US
Practice Address - Phone:781-395-5629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty