1629649009 NPI number — DR. GRACEN MCGUCKIN MARRIOTT DDS

Table of content: KYLE W BAILEY (NPI 1669073573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629649009 NPI number — DR. GRACEN MCGUCKIN MARRIOTT DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRIOTT
Provider First Name:
GRACEN
Provider Middle Name:
MCGUCKIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGUCKIN
Provider Other First Name:
GRACEN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629649009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7838 HUEBNER RD APT 4107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-6126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11200 MENCHACA RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-2747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-646-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 38839 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com