Provider Demographics
NPI:1790942415
Name:GRACE DENTAL DESIGN
Entity Type:Organization
Organization Name:GRACE DENTAL DESIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-840-3424
Mailing Address - Street 1:5619 N PENN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7769
Mailing Address - Country:US
Mailing Address - Phone:405-840-3424
Mailing Address - Fax:405-840-3596
Practice Address - Street 1:5619 N PENN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7769
Practice Address - Country:US
Practice Address - Phone:405-840-3424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty