| NPI | 1659964179 |
|---|---|
| Doing Business As | GRAND AVENUE DENTAL, LLC |
| Entity Type | Organization |
| Authorized Contact | ROBERT SCOTT TYLER Business Manager 651-291-9667 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2021-02-16 |
| Last Update Date | 2021-02-16 |