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General NPI Number Information
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NPI Number | 1225156391
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Entity Type | Organization
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Legal Business Name | GRAND FAMILY DENTISTRY. COM
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 10/17/2016
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Provider Practice Location Address
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Address Line | 2083 3RD ST
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City | MANDEVILLE
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State | LA
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Zip | 70471-6426
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Country | US
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Telephone | 985-231-5796
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Fax | 985-624-8881
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Provider Business Mailing Address
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Address Line | 700 ASBURY DR
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City | MANDEVILLE
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State | LA
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Zip | 70471-1844
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Country | US
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Telephone | 985-231-5796
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Fax | 985-624-8881
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WILLIAM BRADLEY GRAND
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Credential | D.D.S.
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Telephone | 985-778-0096
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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 | 122300000X
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License Number State | LA
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