MEDICARE: D. G. GRANDAL DDS, CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1790006823	OTHER	FL	GENERAL PRACTICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255806592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D. G. GRANDAL DDS, CORP

Provider Business Mailing Address
First Line	:	4605 SW 140TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-3631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13055 SW 42ND ST STE 206
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-3410
Country	:	US
Telephone Number	:	305-846-9669
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DELIO GARCIA
Credential	:
Telephone Number	:	786-556-2950

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	10/12/2018

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