Provider Demographics
NPI:1316073588
Name:GRAND, LEA (DMD)
Entity type:Individual
Prefix:DR
First Name:LEA
Middle Name:
Last Name:GRAND
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1418
Mailing Address - Country:US
Mailing Address - Phone:732-247-3684
Mailing Address - Fax:
Practice Address - Street 1:180 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1418
Practice Address - Country:US
Practice Address - Phone:732-247-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ178831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice