MEDICARE: JERRY D GRAGG DDS

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	122300000X	Dentist	2473	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548575335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY D GRAGG DDS

Provider Business Mailing Address
First Line	:	3489 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3968
Country	:	US
Telephone Number	:	414-445-4111
Fax Number	:	414-445-4103

Provider Business Practice Location Address
First Line	:	3489 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3968
Country	:	US
Telephone Number	:	414-445-4111
Fax Number	:	414-445-4103

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LINDA MCDERMOTT
Credential	:
Telephone Number	:	414-445-4111

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	08/17/2010

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