Healthcare Provider Details

I. General information

NPI: 1285704122
Provider Name (Legal Business Name): JONELLE SENITA GRANT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4837 BENNING RD SE
WASHINGTON DC
20019-6145
US

IV. Provider business mailing address

100 I ST SE APT 1117
WASHINGTON DC
20003-4873
US

V. Phone/Fax

Practice location:
  • Phone: 202-650-5238
  • Fax:
Mailing address:
  • Phone: 919-641-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8228
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN1000885
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: