Provider Demographics
NPI:1316477144
Name:GRACE DENTAL PLLC
Entity type:Organization
Organization Name:GRACE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:931-648-4100
Mailing Address - Street 1:304 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4326
Mailing Address - Country:US
Mailing Address - Phone:931-648-4100
Mailing Address - Fax:931-648-4988
Practice Address - Street 1:304 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:931-648-4100
Practice Address - Fax:931-648-4988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ037677Medicaid