MEDICARE: GRACE TRAVERS DDS

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	122300000X	Dentist	018001805	IL
2	122300000X	Dentist	61514	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61514	OTHER	CA	DENTIST

General Provider Information

NPI Number	:	1639464597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE TRAVERS DDS

Provider Business Mailing Address
First Line	:	828 JACKMAN ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3053
Country	:	US
Telephone Number	:	619-343-8167
Fax Number	:

Provider Business Practice Location Address
First Line	:	828 JACKMAN ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3053
Country	:	US
Telephone Number	:	619-343-8167
Fax Number	:

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

Provider Enumeration Date	:	06/17/2011
Last Update Date	:	12/03/2021

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Directions to “ GRACE TRAVERS DDS” Practice Location

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