Provider Demographics
NPI:1871258913
Name:GRACE PEDIATRIC DENTAL CARE LLC
Entity Type:Organization
Organization Name:GRACE PEDIATRIC DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:IKPECHUKWU
Authorized Official - Last Name:EFOBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-831-6852
Mailing Address - Street 1:2115 LOGANVILLE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1771
Mailing Address - Country:US
Mailing Address - Phone:470-508-0125
Mailing Address - Fax:
Practice Address - Street 1:2115 LOGANVILLE HWY STE 101
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1771
Practice Address - Country:US
Practice Address - Phone:470-508-0125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental