Provider Demographics
NPI:1700041639
Name:GRANNUM, GIA SHAREE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GIA
Middle Name:SHAREE
Last Name:GRANNUM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:GIA
Other - Middle Name:SHAREE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3711 LAKE ENCLAVE WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-1891
Mailing Address - Country:US
Mailing Address - Phone:404-309-0349
Mailing Address - Fax:
Practice Address - Street 1:3711 LAKE ENCLAVE WAY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-1891
Practice Address - Country:US
Practice Address - Phone:404-309-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25502122300000X, 1223P0221X
GADN0139241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121519Medicaid