1225274517 NPI number — NIGEL D. GRANDISON, DMD

Table of content: (NPI 1225274517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225274517 NPI number — NIGEL D. GRANDISON, DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIGEL D. GRANDISON, DMD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KIDS CARE DENTAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225274517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10794 PINES BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-432-1607
Provider Business Mailing Address Fax Number:
954-432-6716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10794 PINES BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-432-1607
Provider Business Practice Location Address Fax Number:
954-432-6716
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRANDISON
Authorized Official First Name:
NIGEL
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
954-432-1607

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  14446 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 013289000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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