MEDICARE: DR. MARK ERNEST GRANGER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	104991	CO

General Provider Information

NPI Number	:	1164490017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ERNEST GRANGER D.D.S.

Provider Business Mailing Address
First Line	:	2525 S WADSWORTH BLVD
Second Line	:	SUITE #23
City	:	LAKEWOOD
State	:	CO
Zip	:	80227-3273
Country	:	US
Telephone Number	:	303-985-0909
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 S WADSWORTH BLVD
Second Line	:	SUITE #23
City	:	LAKEWOOD
State	:	CO
Zip	:	80227-3273
Country	:	US
Telephone Number	:	303-985-0909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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