Healthcare Provider Details

I. General information

NPI: 1366531444
Provider Name (Legal Business Name): JOHN K GRANGER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E WALNUT ST
ROCKFORD OH
45882-0314
US

IV. Provider business mailing address

160 E WALNUT ST
ROCKFORD OH
45882-0314
US

V. Phone/Fax

Practice location:
  • Phone: 419-363-3537
  • Fax: 419-363-3636
Mailing address:
  • Phone: 419-363-3537
  • Fax: 419-363-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14836
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: