=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396852257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FEDERICO GRANDE D.D.S., M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 SE INDIAN ST STE 2
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34997-5565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-510-5900
-----------------------------------------------------
Fax | 772-209-6231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 SE INDIAN ST STE 2
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34997-5565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-510-5900
-----------------------------------------------------
Fax | 772-209-6231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN14859
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------