Provider Demographics
NPI:1306991229
Name:BRACE, TERRELL MACEY (DDS)
Entity type:Individual
Prefix:
First Name:TERRELL
Middle Name:MACEY
Last Name:BRACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 EAST PARIS RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6199
Mailing Address - Country:US
Mailing Address - Phone:616-942-9595
Mailing Address - Fax:616-942-4719
Practice Address - Street 1:2355 EAST PARIS RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6199
Practice Address - Country:US
Practice Address - Phone:616-942-9595
Practice Address - Fax:616-942-4719
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010302122300000X
WI122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist