Provider Demographics
NPI:1548691017
Name:DUCASSE, GRACIELA (DMD)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:DUCASSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 NW 117TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1260
Mailing Address - Country:US
Mailing Address - Phone:857-498-1353
Mailing Address - Fax:
Practice Address - Street 1:1507 N JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3214
Practice Address - Country:US
Practice Address - Phone:079-823-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24672122300000X
MADN1856426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist