Provider Demographics
NPI:1316976863
Name:GRADELESS, MICHAEL R (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:GRADELESS
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 1:10100 LANTERN RD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9686
Mailing Address - Country:US
Mailing Address - Phone:317-841-3130
Mailing Address - Fax:317-841-3007
Practice Address - Street 1:10100 LANTERN RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9651
Practice Address - Country:US
Practice Address - Phone:317-841-3130
Practice Address - Fax:317-841-3007
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN79411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice