Provider Demographics
NPI:1801931019
Name:GRACE, RONALD ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ALAN
Last Name:GRACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:RONALD
Other - Middle Name:RONALD
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:15081 MACCORKLE AVE
Mailing Address - Street 2:BOX 40
Mailing Address - City:CHELYAN
Mailing Address - State:WV
Mailing Address - Zip Code:25035-0040
Mailing Address - Country:US
Mailing Address - Phone:304-595-3551
Mailing Address - Fax:304-595-6822
Practice Address - Street 1:15081 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:CHELYAN
Practice Address - State:WV
Practice Address - Zip Code:25035-0040
Practice Address - Country:US
Practice Address - Phone:304-595-3551
Practice Address - Fax:304-595-6822
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000119839OtherBLUE CROSS BS
WV0137007000Medicaid
119839OtherUNITED CONCORDIA