Healthcare Provider Details

I. General information

NPI: 1558047456
Provider Name (Legal Business Name): HERTA GRANADO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 CENTER ST STE 203
MOUNT AIRY MD
21771-7445
US

IV. Provider business mailing address

5900 WATERLOO RD STE 220
COLUMBIA MD
21045-2638
US

V. Phone/Fax

Practice location:
  • Phone: 301-829-6588
  • Fax:
Mailing address:
  • Phone: 410-630-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number17843
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number17843
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: