Provider Demographics
NPI:1225472749
Name:LISA GRANT ORTHODONTICS
Entity Type:Organization
Organization Name:LISA GRANT ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:708-700-3030
Mailing Address - Street 1:18243 HARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2149
Mailing Address - Country:US
Mailing Address - Phone:708-799-3030
Mailing Address - Fax:
Practice Address - Street 1:18243 HARWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2149
Practice Address - Country:US
Practice Address - Phone:708-799-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210016521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty