Provider Demographics
NPI:1003086810
Name:ROGER GRANDGENETT DDS PA
Entity Type:Organization
Organization Name:ROGER GRANDGENETT DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GRANDGENETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-526-2170
Mailing Address - Street 1:621 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56013-2516
Mailing Address - Country:US
Mailing Address - Phone:507-526-2170
Mailing Address - Fax:507-526-7437
Practice Address - Street 1:621 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BLUE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56013-2516
Practice Address - Country:US
Practice Address - Phone:507-526-2170
Practice Address - Fax:507-526-7437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10869122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty