MEDICARE: DR. ROGER ALAN 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5724	FL

General Provider Information

NPI Number	:	1780648683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER ALAN GRACE D.D.S.

Provider Business Mailing Address
First Line	:	28 RACETRACK RD NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1602
Country	:	US
Telephone Number	:	850-863-2111
Fax Number	:	850-863-5812

Provider Business Practice Location Address
First Line	:	28 RACETRACK RD NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1602
Country	:	US
Telephone Number	:	850-863-2111
Fax Number	:	850-863-5812

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/21/2022

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