Basic Information
| Provider Information | |||||||||
| NPI: | 1437565967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANADOS | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 DOVER RD | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061191214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544100247 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4005 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | BEE CAVE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787386912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122634142 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2014 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | 11203 | CT | N | Dental Providers | Dentist | Endodontics | 390200000X | 11203 | CT | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223E0200X | 37837 | TX | Y | Dental Providers | Dentist | Endodontics |
No ID Information.