Healthcare Provider Details

I. General information

NPI: 1932548799
Provider Name (Legal Business Name): BRYAN GRAZIANO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 PAT D'ARCO HWY UNIT A
BERNALILLO NM
87004
US

IV. Provider business mailing address

470 PAT D'ARCO HWY UNIT A
BERNALILLO NM
87004
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-7444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD008736
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4483
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: