Provider Demographics
NPI:1285303594
Name:GRANT, EVELYN DENISE (RDH, MBA)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:DENISE
Last Name:GRANT
Suffix:
Gender:F
Credentials:RDH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800740
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0740
Mailing Address - Country:US
Mailing Address - Phone:434-982-3597
Mailing Address - Fax:434-243-6378
Practice Address - Street 1:1222 JPA 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-249-3387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402003340124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist