Provider Demographics
NPI:1447790837
Name:GRADY, MARY KATHLEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:GRADY
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 1:1184 SW SILVER LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2194
Mailing Address - Country:US
Mailing Address - Phone:708-307-8967
Mailing Address - Fax:
Practice Address - Street 1:200 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2112
Practice Address - Country:US
Practice Address - Phone:541-548-4064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD108101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice