MEDICARE: GRACE DENTAL CLINIC, P.A.

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	13555	MD

General Provider Information

NPI Number	:	1578736955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE DENTAL CLINIC, P.A.

Provider Business Mailing Address
First Line	:	8850 COLUMBIA 100 PKWY
Second Line	:	SUITE 201
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2374
Country	:	US
Telephone Number	:	410-997-5699
Fax Number	:	410-997-5633

Provider Business Practice Location Address
First Line	:	8850 COLUMBIA 100 PKWY
Second Line	:	SUITE 201
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2374
Country	:	US
Telephone Number	:	410-997-5699
Fax Number	:	410-997-5633

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CHRISTOPHER KEUNYOUNG YOO
Credential	:	D.M.D.
Telephone Number	:	410-997-5699

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	04/08/2008

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