Provider Demographics
NPI:1497489744
Name:GRANGER, KELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:GRANGER
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 1:1301 M ST NW APT 520
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-4222
Mailing Address - Country:US
Mailing Address - Phone:516-729-9830
Mailing Address - Fax:
Practice Address - Street 1:80 E JEFFERSON ST STE 400B
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3569
Practice Address - Country:US
Practice Address - Phone:703-241-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN20001111223P0221X
MD173301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry