Provider Demographics
NPI:1265591531
Name:GRACHEK JR., DAVID JEROME (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JEROME
Last Name:GRACHEK JR.
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13745 NORTHLINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1866
Mailing Address - Country:US
Mailing Address - Phone:734-284-9873
Mailing Address - Fax:734-284-4161
Practice Address - Street 1:13745 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1866
Practice Address - Country:US
Practice Address - Phone:734-284-9873
Practice Address - Fax:734-284-4161
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14866122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist