Provider Demographics
NPI:1780648683
Name:GRACE, ROGER ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:GRACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:28 RACETRACK RD NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1602
Mailing Address - Country:US
Mailing Address - Phone:850-863-2111
Mailing Address - Fax:850-863-5812
Practice Address - Street 1:28 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1602
Practice Address - Country:US
Practice Address - Phone:850-863-2111
Practice Address - Fax:850-863-5812
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL57241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics