MEDICARE: GRACE MARIE MONETTE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DGD.10856	SC

General Provider Information

NPI Number	:	1205673142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE MARIE MONETTE DDS

Provider Business Mailing Address
First Line	:	2839 LAKESHORE ROAD
Second Line	:
City	:	APPLEGATE
State	:	MI
Zip	:	48401
Country	:	US
Telephone Number	:	313-588-0601
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 HIGHWAY 17 S
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3117
Country	:	US
Telephone Number	:	843-492-5861
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2024
Last Update Date	:	07/09/2024

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