Provider Demographics
NPI:1154460228
Name:GRANT, RICHARD (DDS,MS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12374 CARMEL COUNTRY RD
Mailing Address - Street 2:H310
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4523
Mailing Address - Country:US
Mailing Address - Phone:858-205-3872
Mailing Address - Fax:
Practice Address - Street 1:12395 EL CAMINO REAL
Practice Address - Street 2:SUITE 218
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3082
Practice Address - Country:US
Practice Address - Phone:858-755-1515
Practice Address - Fax:858-755-7878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA514121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics