Healthcare Provider Details

I. General information

NPI: 1306920970
Provider Name (Legal Business Name): ANN MARIE GRADY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 E SPRUCE AVE STE 103
FRESNO CA
93720-3378
US

IV. Provider business mailing address

1360 E SPRUCE AVE STE 103
FRESNO CA
93720-3378
US

V. Phone/Fax

Practice location:
  • Phone: 559-860-2500
  • Fax: 559-860-2502
Mailing address:
  • Phone: 559-860-2500
  • Fax: 559-860-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number53741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: