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General NPI Number Information
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NPI Number | 1023543287
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Entity Type | Organization
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Legal Business Name | SAND DOLLAR DENTAL, INC
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Dates
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Enumeration Date | 04/25/2017
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Last Update Date | 04/25/2017
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Provider Practice Location Address
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Address Line | 300 HOLLYWOOD BLVD SE
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-5727
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Country | US
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Telephone | 850-712-2307
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Fax |
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Provider Business Mailing Address
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Address Line | 2631 HIDDEN CREEK DR
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City | NAVARRE
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State | FL
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Zip | 32566-6704
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARL S GRAVES
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Credential | D.D.S.
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Telephone | 850-712-2307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN21942
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License Number State | FL
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