Provider Demographics
NPI:1467135376
Name:GRADY, KRISTEN RENAE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENAE
Last Name:GRADY
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 YASUTAKE RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4811
Mailing Address - Country:US
Mailing Address - Phone:253-221-1200
Mailing Address - Fax:
Practice Address - Street 1:MONTGOMERY DRIVE #339
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819
Practice Address - Country:US
Practice Address - Phone:808-438-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402208146124Q00000X
HIDH-2431-0124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist