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General NPI Number Information
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NPI Number | 1669958740
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Entity Type | Organization
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Legal Business Name | MA DENTAL
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Dates
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Enumeration Date | 07/12/2018
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Last Update Date | 07/12/2018
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Provider Practice Location Address
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Address Line | 530 FLORIDA AVENUE
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City | LYNN HAVEN
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State | FL
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Zip | 32444-1736
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Country | US
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Telephone | 850-271-2341
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Fax | 850-271-0679
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Provider Business Mailing Address
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Address Line | 530 FLORIDA AVENUE
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City | LYNN HAVEN
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State | FL
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Zip | 32444-1736
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Country | US
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Telephone | 850-271-2341
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Fax | 850-271-0679
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. MICHAEL SCOTT GRANDY
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Credential | DMD
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Telephone | 850-271-2341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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