Provider Demographics
NPI:1659524452
Name:SETIAWAN, GRACE (DDS)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SETIAWAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 N GALLOWAY AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7535
Mailing Address - Country:US
Mailing Address - Phone:972-686-6477
Mailing Address - Fax:972-613-7504
Practice Address - Street 1:5115 N GALLOWAY AVE STE 301
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-7535
Practice Address - Country:US
Practice Address - Phone:972-686-6477
Practice Address - Fax:972-613-7504
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist