Basic Information
| Provider Information | |||||||||
| NPI: | 1003993502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANNUM | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | ORAL SURGERY ROOM 2C230 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | ORAL SURGERY ROOM 2C320 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7185994912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 50052633 | NY | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03084764 | 05 | NY | MEDICAID |