Provider Demographics
NPI:1417659145
Name:RACHID, CARLY ANNE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANNE
Last Name:RACHID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ANNE
Other - Last Name:GRIMISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6000 TOSCANA DR APT 428
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN279021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice