Provider Demographics
NPI:1790873909
Name:GRADY, GREGORY H (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:H
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 1:4121 OKEMOS RD STE 20
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3220
Mailing Address - Country:US
Mailing Address - Phone:517-349-0388
Mailing Address - Fax:517-349-1589
Practice Address - Street 1:4121 OKEMOS RD STE 20
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3220
Practice Address - Country:US
Practice Address - Phone:517-349-0388
Practice Address - Fax:517-349-1589
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0154391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice