MEDICARE: DAVID LEE GRACE D.D.S.

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	1223G0001X	General Practice Dentistry	2331	AR

General Provider Information

NPI Number	:	1336294008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LEE GRACE D.D.S.

Provider Business Mailing Address
First Line	:	2017 N GREEN ACRES RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2619
Country	:	US
Telephone Number	:	479-442-9871
Fax Number	:	479-444-0043

Provider Business Practice Location Address
First Line	:	2017 N GREEN ACRES RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2619
Country	:	US
Telephone Number	:	479-442-9871
Fax Number	:	479-444-0043

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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