Healthcare Provider Details

I. General information

NPI: 1619123296
Provider Name (Legal Business Name): AMELIA B GRANBERRY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13570 N MAIN ST
TRENTON GA
30752-2012
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-657-7575
  • Fax: 706-657-4430
Mailing address:
  • Phone: 706-657-7575
  • Fax: 706-657-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: