Healthcare Provider Details

I. General information

NPI: 1396852257
Provider Name (Legal Business Name): FEDERICO GRANDE D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 SE INDIAN ST STE 2
STUART FL
34997-5565
US

IV. Provider business mailing address

650 SE INDIAN ST STE 2
STUART FL
34997-5565
US

V. Phone/Fax

Practice location:
  • Phone: 772-510-5900
  • Fax: 772-209-6231
Mailing address:
  • Phone: 772-510-5900
  • Fax: 772-209-6231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN14859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: