Provider Demographics
NPI:1518094242
Name:GRAGG, JEFFREY R (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:GRAGG
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 1:237 W MULBERRY
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:IA
Mailing Address - Zip Code:50212-0813
Mailing Address - Country:US
Mailing Address - Phone:515-275-2250
Mailing Address - Fax:515-275-2816
Practice Address - Street 1:237 W MULBERRY
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:IA
Practice Address - Zip Code:50212-0813
Practice Address - Country:US
Practice Address - Phone:515-275-2250
Practice Address - Fax:515-275-2816
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0449629Medicaid