Provider Demographics
NPI:1639362643
Name:GRADY, LINDSAY (DDS)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:GRADY
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 1:11121 FAIR OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-5136
Mailing Address - Country:US
Mailing Address - Phone:916-961-6810
Mailing Address - Fax:916-961-6445
Practice Address - Street 1:11121 FAIR OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5136
Practice Address - Country:US
Practice Address - Phone:916-961-6810
Practice Address - Fax:916-961-6445
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist