Provider Demographics
NPI:1033476239
Name:GRANITE SPRINGS DENTISTRY, LLC
Entity Type:Organization
Organization Name:GRANITE SPRINGS DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MERRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-670-0798
Mailing Address - Street 1:2316 DELL RANGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-5191
Mailing Address - Country:US
Mailing Address - Phone:720-670-0798
Mailing Address - Fax:
Practice Address - Street 1:2316 DELL RANGE BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-5191
Practice Address - Country:US
Practice Address - Phone:720-670-0798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty