=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881869055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SW GRANT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2008
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2275 S EAGLE RD STE 140
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-938-3190
-----------------------------------------------------
Fax | 208-888-1571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2275 S EAGLE RD STE 140
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-938-3190
-----------------------------------------------------
Fax | 208-888-1571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SCOTT WILLIAM GRANT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 208-938-3190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D-3981
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------