Healthcare Provider Details

I. General information

NPI: 1982914305
Provider Name (Legal Business Name): KC GRANGER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 ENTERPRISE RD
MITCHELLEVILLE MD
20721-1834
US

IV. Provider business mailing address

1211 ENTERPRISE RD
BOWIE MD
20721-1909
US

V. Phone/Fax

Practice location:
  • Phone: 301-249-3333
  • Fax:
Mailing address:
  • Phone: 615-480-5562
  • Fax: 301-249-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14112
License Number StateMD

VIII. Authorized Official

Name: KEVIN GRANGER
Title or Position: OWNER
Credential: DDS
Phone: 301-249-3333