Provider Demographics
NPI:1558090985
Name:COLEMAN, GRANT JOSEPH
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:JOSEPH
Last Name:COLEMAN
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 1:1823 MORSE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12355 POTRANCO RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5847
Practice Address - Country:US
Practice Address - Phone:210-934-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX384291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice