Provider Demographics
NPI:1841086584
Name:SHELBY GRACE DENTAL PLLC
Entity type:Organization
Organization Name:SHELBY GRACE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRISOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-873-6589
Mailing Address - Street 1:4872 ALTON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5007
Mailing Address - Country:US
Mailing Address - Phone:586-873-6589
Mailing Address - Fax:
Practice Address - Street 1:47100 SCHOENHERR RD STE A
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4714
Practice Address - Country:US
Practice Address - Phone:586-566-8338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental