Provider Demographics
NPI:1073529962
Name:GRANT, JENNIFER ERIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ERIN
Last Name:GRANT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ERIN
Other - Last Name:MATKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 LAKE SUCCESS DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2908
Mailing Address - Country:US
Mailing Address - Phone:254-235-4986
Mailing Address - Fax:254-235-5023
Practice Address - Street 1:1601 LAKE SUCCESS DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2908
Practice Address - Country:US
Practice Address - Phone:254-235-4986
Practice Address - Fax:254-235-5023
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice