Healthcare Provider Details

I. General information

NPI: 1457588055
Provider Name (Legal Business Name): GRANT AND PHAM DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9710 WINTER GARDENS BLVD
LAKESIDE CA
92040-3866
US

IV. Provider business mailing address

9710 WINTER GARDENS BLVD
LAKESIDE CA
92040-3866
US

V. Phone/Fax

Practice location:
  • Phone: 619-443-8447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number52916
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51412
License Number StateCA

VIII. Authorized Official

Name: RICHARD GRANT
Title or Position: OWNER
Credential:
Phone: 858-205-3872