Provider Demographics
NPI:1770750028
Name:GRANDGENETT FAMILY DENTAL, PC
Entity type:Organization
Organization Name:GRANDGENETT FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANDGENETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-956-3426
Mailing Address - Street 1:2208 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8700
Mailing Address - Country:US
Mailing Address - Phone:515-956-3426
Mailing Address - Fax:515-956-3424
Practice Address - Street 1:2208 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8700
Practice Address - Country:US
Practice Address - Phone:515-956-3426
Practice Address - Fax:515-956-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079461223P0221X
IA079311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty