Provider Demographics
NPI:1689175697
Name:GRANT, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GRANT
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 1:1714 GAMBEL QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6354
Mailing Address - Country:US
Mailing Address - Phone:915-261-3698
Mailing Address - Fax:
Practice Address - Street 1:6901 HELEN OF TROY STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79911-3049
Practice Address - Country:US
Practice Address - Phone:915-845-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33973122300000X, 1223P0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program