Healthcare Provider Details

I. General information

NPI: 1932287380
Provider Name (Legal Business Name): RICHARD DAMIEN GRANT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 JONESBORO RD STE 7
UNION CITY GA
30291-1956
US

IV. Provider business mailing address

4720 JONESBORO RD STE 7
UNION CITY GA
30291-1956
US

V. Phone/Fax

Practice location:
  • Phone: 770-696-6444
  • Fax: 770-969-7008
Mailing address:
  • Phone: 770-696-6444
  • Fax: 770-969-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: