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General NPI Number Information
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NPI Number | 1568600757
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Entity Type | Organization
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Legal Business Name | ROGER GRANNUM DDS, P.C.
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Dates
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Enumeration Date | 01/27/2009
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Last Update Date | 09/29/2011
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Provider Practice Location Address
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Address Line | 730 BROADWAY
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City | BROOKLYN
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State | NY
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Zip | 11206-4403
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Country | US
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Telephone | 917-816-0481
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Fax |
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Provider Business Mailing Address
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Address Line | 131 KNOLLWOOD DR
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City | WATCHUNG
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State | NJ
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Zip | 07069-6245
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Country | US
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Telephone | 917-816-0481
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DR. ROGER GRANNUM
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Credential | DDS
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Telephone | 917-816-0481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 052633
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License Number State | NY
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