Provider Demographics
NPI:1992864375
Name:GRANGER, MICHAEL W (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:GRANGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:WADE
Other - Last Name:GRANGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:745 BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2030
Mailing Address - Country:US
Mailing Address - Phone:770-461-4142
Mailing Address - Fax:770-719-8862
Practice Address - Street 1:745 BRADLEY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2030
Practice Address - Country:US
Practice Address - Phone:770-461-4142
Practice Address - Fax:770-719-8862
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0114131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics