Provider Demographics
NPI:1437565967
Name:GRANADOS, JEREMIAH M (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:M
Last Name:GRANADOS
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 1:148 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1214
Mailing Address - Country:US
Mailing Address - Phone:954-410-0247
Mailing Address - Fax:
Practice Address - Street 1:4005 MARKET ST
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-6912
Practice Address - Country:US
Practice Address - Phone:512-263-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-04
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT112031223E0200X, 390200000X
TX378371223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program