Healthcare Provider Details

I. General information

NPI: 1699776690
Provider Name (Legal Business Name): GERALD THOMAS GRANT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

700 SARASOTA ARCH
CHESAPEAKE VA
23322-6852
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-5828
  • Fax: 301-295-5767
Mailing address:
  • Phone: 757-546-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5974
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: