Provider Demographics
NPI:1548471592
Name:GARBO, GRACE (DDS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GARBO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 HIGHWAY 190 W
Mailing Address - Street 2:SUITE D
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-6023
Mailing Address - Country:US
Mailing Address - Phone:337-463-6545
Mailing Address - Fax:337-462-3908
Practice Address - Street 1:1808 HIGHWAY 190 W
Practice Address - Street 2:SUITE D
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-6023
Practice Address - Country:US
Practice Address - Phone:337-463-6545
Practice Address - Fax:337-462-3908
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice