Provider Demographics
NPI:1699134171
Name:LAINE, GRACE K
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:LAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6814 S HESPERIDES ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2536
Mailing Address - Country:US
Mailing Address - Phone:954-294-8860
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22658124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist