Provider Demographics
NPI:1063569929
Name:ANN MARIE GRADY, D.D.S., PC
Entity type:Organization
Organization Name:ANN MARIE GRADY, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-435-7993
Mailing Address - Street 1:1313 E. HERNDON AVE. #104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-435-7993
Mailing Address - Fax:559-435-7935
Practice Address - Street 1:1313 E HERNDON AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3306
Practice Address - Country:US
Practice Address - Phone:559-435-7993
Practice Address - Fax:559-435-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537411223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53741OtherDENTAL LICENSE
CADS0537410Medicare ID - Type UnspecifiedMEDICARE