Provider Demographics
NPI:1578248092
Name:GRANT DMSO LLC
Entity Type:Organization
Organization Name:GRANT DMSO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:DHAENENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-372-9999
Mailing Address - Street 1:6288 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-5831
Mailing Address - Country:US
Mailing Address - Phone:702-525-4500
Mailing Address - Fax:
Practice Address - Street 1:6288 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5831
Practice Address - Country:US
Practice Address - Phone:520-372-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental