Healthcare Provider Details

I. General information

NPI: 1770750028
Provider Name (Legal Business Name): GRANDGENETT FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 PHILADELPHIA ST
AMES IA
50010-8700
US

IV. Provider business mailing address

2208 PHILADELPHIA ST
AMES IA
50010-8700
US

V. Phone/Fax

Practice location:
  • Phone: 515-956-3426
  • Fax: 515-956-3424
Mailing address:
  • Phone: 515-956-3426
  • Fax: 515-956-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number07931
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number07946
License Number StateIA

VIII. Authorized Official

Name: DR. CRAIG A GRANDGENETT
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 515-956-3426