Healthcare Provider Details

I. General information

NPI: 1477714384
Provider Name (Legal Business Name): GREGORY P GRANTHAM DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W 23RD ST SUITE A
PANAMA CITY FL
32405-7600
US

IV. Provider business mailing address

340 W 23RD ST SUITE A
PANAMA CITY FL
32405-7600
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-3253
  • Fax: 850-784-0057
Mailing address:
  • Phone: 850-769-3253
  • Fax: 850-784-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN4098
License Number StateFL

VIII. Authorized Official

Name: DR. GREGORY P GRANTHAM
Title or Position: OWNER/PHYSICIAN
Credential: DMD
Phone: 850-769-3253