Healthcare Provider Details

I. General information

NPI: 1710927843
Provider Name (Legal Business Name): ROBERT MARK GRACE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMMUNITY HEALTH CENTER 400 TEAGARDEN
LA PORTE IN
46350-3175
US

IV. Provider business mailing address

1007 LINCOLNWAY POST OFFICE BOX 1539
LAPORTE IN
46350-3201
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-2403
  • Fax: 219-326-2385
Mailing address:
  • Phone: 219-326-2403
  • Fax: 219-326-2385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number12007607A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: