Provider Demographics
NPI:1730481011
Name:LA, GRACE E (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:E
Last Name:LA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 MAIN ST
Mailing Address - Street 2:GENTLE DENTAL
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:339 MAIN ST
Practice Address - Street 2:GENTLE DENTAL
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1514
Practice Address - Country:US
Practice Address - Phone:207-283-3775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist