Provider Demographics
NPI:1124248240
Name:GRANBERRY, DENNIS LEE (DDS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:LEE
Last Name:GRANBERRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#9 PROFESSIONAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-264-2200
Mailing Address - Fax:601-268-6068
Practice Address - Street 1:#9 PROFESSIONAL PARKWAY
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-264-2200
Practice Address - Fax:601-268-6068
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1362691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660123Medicaid