Provider Demographics
NPI:1467439281
Name:GRANGER, KEVIN C (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
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 1:8363B GREENSBORO DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3530
Mailing Address - Country:US
Mailing Address - Phone:615-480-5562
Mailing Address - Fax:703-556-9760
Practice Address - Street 1:2415 BENNING RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4827
Practice Address - Country:US
Practice Address - Phone:202-396-9679
Practice Address - Fax:202-396-9773
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT22045122300000X
MD14112122300000X
VA0401411967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170550101Medicaid
DC049045800Medicaid
MD039607900Medicaid
DC051370400Medicaid
MD039607900Medicaid