Provider Demographics
NPI:1992017008
Name:GRADY, ALICIA ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ANNE
Last Name:GRADY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7905 MARBLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7886
Mailing Address - Country:US
Mailing Address - Phone:505-232-5710
Mailing Address - Fax:
Practice Address - Street 1:7905 MARBLE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7886
Practice Address - Country:US
Practice Address - Phone:505-232-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD34571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice