Provider Demographics
NPI:1114591310
Name:GRANEY, KYLIE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:GRANEY
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:MSC 09 5020 1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-925-4031
Mailing Address - Fax:505-272-5584
Practice Address - Street 1:352 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-3106
Practice Address - Country:US
Practice Address - Phone:307-745-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMTD-00-146390200000X
NM390200000X
WY1605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program