Provider Demographics
NPI:1609980077
Name:GRAGG, KIMBERLY LUTZ (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LUTZ
Last Name:GRAGG
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S GREEN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3526
Mailing Address - Country:US
Mailing Address - Phone:828-438-8998
Mailing Address - Fax:828-438-8898
Practice Address - Street 1:303 S GREEN ST STE 201
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3526
Practice Address - Country:US
Practice Address - Phone:828-438-8998
Practice Address - Fax:828-438-8898
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-902A1Medicaid