Provider Demographics
NPI:1376766956
Name:GRANT, BENJAMIN HOWARD
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HOWARD
Last Name:GRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 LAVISTA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1006
Mailing Address - Country:US
Mailing Address - Phone:404-634-2205
Mailing Address - Fax:404-982-9210
Practice Address - Street 1:3744 LAVISTA RD
Practice Address - Street 2:SUITE B
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-1006
Practice Address - Country:US
Practice Address - Phone:404-634-2205
Practice Address - Fax:404-982-9210
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice