Healthcare Provider Details

I. General information

NPI: 1811090004
Provider Name (Legal Business Name): GRANT K NAKASHIMA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SAN GABRIEL VILLAGE BLVD
GEORGETOWN TX
78626-5594
US

IV. Provider business mailing address

701 SAN GABRIEL VILLAGE BLVD
GEORGETOWN TX
78626-5594
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-2233
  • Fax: 512-868-2210
Mailing address:
  • Phone: 512-868-2233
  • Fax: 512-868-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20441
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: