Provider Demographics
NPI:1598061640
Name:GRACE DENT P.A.
Entity Type:Organization
Organization Name:GRACE DENT P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPIONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-416-7714
Mailing Address - Street 1:N4W22370 BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1683
Mailing Address - Country:US
Mailing Address - Phone:262-970-5610
Mailing Address - Fax:
Practice Address - Street 1:N4W22370 BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1683
Practice Address - Country:US
Practice Address - Phone:262-970-5610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4356-12111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty