Healthcare Provider Details

I. General information

NPI: 1447251574
Provider Name (Legal Business Name): GRANT R HARTUP DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HQ USAF/SGCD 110 LUKE AVE, ROOM 400
BOLLING AFB DC
20032
US

IV. Provider business mailing address

8092 PAPER BIRCH DR
LORTON VA
22079-5654
US

V. Phone/Fax

Practice location:
  • Phone: 202-767-4385
  • Fax:
Mailing address:
  • Phone: 703-495-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9740
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: