Provider Demographics
NPI:1366531444
Name:GRANGER, JOHN K (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:GRANGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45882-0314
Mailing Address - Country:US
Mailing Address - Phone:419-363-3537
Mailing Address - Fax:419-363-3636
Practice Address - Street 1:160 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882-0314
Practice Address - Country:US
Practice Address - Phone:419-363-3537
Practice Address - Fax:419-363-3636
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH148361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0326132Medicaid