Provider Demographics
NPI:1275661712
Name:GRANGER, GARY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:GRANGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 MONTREAU CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2737
Mailing Address - Country:US
Mailing Address - Phone:817-860-5220
Mailing Address - Fax:
Practice Address - Street 1:4351 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4917
Practice Address - Country:US
Practice Address - Phone:817-926-6677
Practice Address - Fax:817-926-6679
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT13540Medicare UPIN