Provider Demographics
NPI:1902035744
Name:GARCIA-DIZON, GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:GARCIA-DIZON
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 1:817 MAIDEN CHOICE LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3680
Mailing Address - Country:US
Mailing Address - Phone:410-247-4748
Mailing Address - Fax:410-247-4782
Practice Address - Street 1:817 MAIDEN CHOICE LN
Practice Address - Street 2:SUITE 220
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-3680
Practice Address - Country:US
Practice Address - Phone:410-247-4748
Practice Address - Fax:410-247-4782
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2013-11-19
Deactivation Date:2012-08-14
Deactivation Code:
Reactivation Date:2013-08-07
Provider Licenses
StateLicense IDTaxonomies
MD119231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice