Provider Demographics
NPI:1710927843
Name:GRACE, ROBERT MARK (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARK
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 1:1007 LINCOLNWAY
Mailing Address - Street 2:POST OFFICE BOX 1539
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3201
Mailing Address - Country:US
Mailing Address - Phone:219-326-2403
Mailing Address - Fax:219-326-2385
Practice Address - Street 1:COMMUNITY HEALTH CENTER
Practice Address - Street 2:400 TEAGARDEN
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3175
Practice Address - Country:US
Practice Address - Phone:219-326-2403
Practice Address - Fax:219-326-2385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007607A1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940640GGGMedicare ID - Type Unspecified
INV07059Medicare UPIN