Provider Demographics
NPI:1407229008
Name:KEVIN J. GRANT D.D.S.,P.C.
Entity Type:Organization
Organization Name:KEVIN J. GRANT D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-523-7679
Mailing Address - Street 1:8752A PARSONS BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3317
Mailing Address - Country:US
Mailing Address - Phone:718-523-7679
Mailing Address - Fax:718-523-7689
Practice Address - Street 1:8752A PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3317
Practice Address - Country:US
Practice Address - Phone:718-523-7679
Practice Address - Fax:718-523-7689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01383568Medicaid