Provider Demographics
NPI:1710218961
Name:GRAND, DOMENIC JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:JOHN
Last Name:GRAND
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 1:31 ROUTE #23
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419
Mailing Address - Country:US
Mailing Address - Phone:973-827-3756
Mailing Address - Fax:973-827-3350
Practice Address - Street 1:31 ROUTE #23
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419
Practice Address - Country:US
Practice Address - Phone:973-827-3756
Practice Address - Fax:973-827-3350
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ8061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist