Provider Demographics
NPI:1275507345
Name:GRANT, JOHN S (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:GRANT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6217 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-3096
Mailing Address - Country:US
Mailing Address - Phone:414-764-5550
Mailing Address - Fax:414-764-8175
Practice Address - Street 1:6217 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3096
Practice Address - Country:US
Practice Address - Phone:414-764-5550
Practice Address - Fax:414-764-8175
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50013341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice