Provider Demographics
NPI:1013039528
Name:GRANT DAVIS DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:GRANT DAVIS DENTAL ASSOCIATES PC
Other - Org Name:GRANT DAVIS GRIBBLE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-898-1976
Mailing Address - Street 1:3610 CALLE CUERVO NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-8904
Mailing Address - Country:US
Mailing Address - Phone:505-898-1976
Mailing Address - Fax:505-792-0708
Practice Address - Street 1:3610 CALLE CUERVO NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-8904
Practice Address - Country:US
Practice Address - Phone:505-898-1976
Practice Address - Fax:505-792-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty