Provider Demographics
NPI:1619030160
Name:LO, GRANT SHIH MING (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:SHIH MING
Last Name:LO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 GRIFFIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022
Mailing Address - Country:US
Mailing Address - Phone:360-825-2191
Mailing Address - Fax:360-825-1830
Practice Address - Street 1:2617 GRIFFIN AVENUE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022
Practice Address - Country:US
Practice Address - Phone:360-825-2191
Practice Address - Fax:360-825-1830
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA90581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5043567Medicaid