MEDICARE: DR. GRACE E LA D.M.D

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	122300000X	Dentist	DEN4166	ME

General Provider Information

NPI Number	:	1730481011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE E LA D.M.D

Provider Business Mailing Address
First Line	:	339 MAIN ST
Second Line	:	GENTLE DENTAL
City	:	SACO
State	:	ME
Zip	:	04072-1514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	339 MAIN ST
Second Line	:	GENTLE DENTAL
City	:	SACO
State	:	ME
Zip	:	04072-1514
Country	:	US
Telephone Number	:	207-283-3775
Fax Number	:

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

Provider Enumeration Date	:	11/19/2010
Last Update Date	:	03/23/2011

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