Healthcare Provider Details

I. General information

NPI: 1639388697
Provider Name (Legal Business Name): KENT W. GRAGG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 WEST MULBERRY
OGDEN IA
50212-0813
US

IV. Provider business mailing address

422 OLYMPIC DR
WATERLOO IA
50701-4972
US

V. Phone/Fax

Practice location:
  • Phone: 515-275-2250
  • Fax: 515-275-2816
Mailing address:
  • Phone: 319-232-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6265
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: