MEDICARE: GRACE PEDIATRIC DENTAL CARE LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1871258913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE PEDIATRIC DENTAL CARE LLC

Provider Business Mailing Address
First Line	:	2115 LOGANVILLE HWY STE 101
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-1771
Country	:	US
Telephone Number	:	470-508-0125
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 LOGANVILLE HWY STE 101
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-1771
Country	:	US
Telephone Number	:	470-508-0125
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TABITHA IKPECHUKWU EFOBI
Credential	:
Telephone Number	:	757-831-6852

Provider Enumeration Date	:	11/03/2021
Last Update Date	:	11/03/2021

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