Healthcare Provider Details

I. General information

NPI: 1669958740
Provider Name (Legal Business Name): MA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 FLORIDA AVENUE
LYNN HAVEN FL
32444-1736
US

IV. Provider business mailing address

530 FLORIDA AVENUE
LYNN HAVEN FL
32444-1736
US

V. Phone/Fax

Practice location:
  • Phone: 850-271-2341
  • Fax: 850-271-0679
Mailing address:
  • Phone: 850-271-2341
  • Fax: 850-271-0679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL SCOTT GRANDY
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 850-271-2341