Healthcare Provider Details

I. General information

NPI: 1720501380
Provider Name (Legal Business Name): LION GRENADER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 SHERIDAN RD # D
WINTHROP HARBOR IL
60096-1350
US

IV. Provider business mailing address

400 PENNY LN
GRAYSLAKE IL
60030-3737
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-5626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019031298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: