Healthcare Provider Details

I. General information

NPI: 1033255609
Provider Name (Legal Business Name): WILLIAM DAVID GRANBERRY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WEST VETERANS MEMORIAL DRIVE
KAPLAN LA
70548
US

IV. Provider business mailing address

1600 WEST VETERANS MEMORIAL DRIVE
KAPLAN LA
70548
US

V. Phone/Fax

Practice location:
  • Phone: 337-643-6400
  • Fax: 337-643-6401
Mailing address:
  • Phone: 337-643-6400
  • Fax: 337-643-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3407
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: