Provider Demographics
NPI:1952683609
Name:GRANICA, JOSEPH BRADLEY (RDH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:BRADLEY
Last Name:GRANICA
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15910 W COMPANY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5320
Mailing Address - Country:US
Mailing Address - Phone:715-934-2224
Mailing Address - Fax:715-934-5740
Practice Address - Street 1:15910 W COMPANY LAKE RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5320
Practice Address - Country:US
Practice Address - Phone:715-934-2224
Practice Address - Fax:715-934-5740
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11027-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist