Provider Demographics
NPI:1689801177
Name:GRANT, VANISIA
Entity Type:Individual
Prefix:DR
First Name:VANISIA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S US 301
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5141
Mailing Address - Country:US
Mailing Address - Phone:352-793-5900
Mailing Address - Fax:352-793-8114
Practice Address - Street 1:1389 S US 301
Practice Address - Street 2:
Practice Address - City:SUMTERVILLE
Practice Address - State:FL
Practice Address - Zip Code:33585-5143
Practice Address - Country:US
Practice Address - Phone:352-793-5900
Practice Address - Fax:352-793-8114
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice