Provider Demographics
NPI:1578773693
Name:GRACE, PERRY LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:LOUIS
Last Name:GRACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAVALLETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:08735-2515
Mailing Address - Country:US
Mailing Address - Phone:732-830-0300
Mailing Address - Fax:732-830-8033
Practice Address - Street 1:1807 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAVALLETTE
Practice Address - State:NJ
Practice Address - Zip Code:08735-2515
Practice Address - Country:US
Practice Address - Phone:732-830-0300
Practice Address - Fax:732-830-8033
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDIO165941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22-2937754OtherEIN