Provider Demographics
NPI:1194898767
Name:GRANT, SCOTT WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:GRANT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 S EAGLE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2620
Mailing Address - Country:US
Mailing Address - Phone:208-938-3190
Mailing Address - Fax:208-888-1571
Practice Address - Street 1:2275 S EAGLE RD STE 140
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2620
Practice Address - Country:US
Practice Address - Phone:208-938-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00001890338OtherUNITED CONCORDIA
ID000010157447OtherBLUE SHIELD
ID807480600Medicaid
ID6P052OtherBLUE CROSS