Provider Demographics
NPI:1609208743
Name:MACE, DANIELLE LARAE (DDS)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LARAE
Last Name:MACE
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 1:250 VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-7301
Mailing Address - Country:US
Mailing Address - Phone:304-241-4992
Mailing Address - Fax:304-241-4023
Practice Address - Street 1:250 VENTURE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-7301
Practice Address - Country:US
Practice Address - Phone:304-241-4992
Practice Address - Fax:304-241-4023
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice