Provider Demographics
NPI:1447571054
Name:GRAND FAMILY DENTISTRY. COM
Entity Type:Organization
Organization Name:GRAND FAMILY DENTISTRY. COM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-372-7699
Mailing Address - Street 1:700 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1844
Mailing Address - Country:US
Mailing Address - Phone:225-372-7699
Mailing Address - Fax:225-292-7200
Practice Address - Street 1:12117 COURSEY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-4410
Practice Address - Country:US
Practice Address - Phone:225-292-0016
Practice Address - Fax:225-292-7200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty