Healthcare Provider Details

I. General information

NPI: 1396991733
Provider Name (Legal Business Name): JEREMY E GRABE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6099 N 1ST ST STE 104
FRESNO CA
93710-5462
US

IV. Provider business mailing address

6099 N 1ST ST STE 104
FRESNO CA
93710-5462
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-1400
  • Fax: 559-431-1590
Mailing address:
  • Phone: 559-431-1400
  • Fax: 559-431-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: