Provider Demographics
NPI:1750454906
Name:SMITH, GRANT ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:13345 32ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2635
Mailing Address - Country:US
Mailing Address - Phone:763-383-0484
Mailing Address - Fax:763-383-0486
Practice Address - Street 1:4190 VINEWOOD LN N
Practice Address - Street 2:SUITE 109
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-1735
Practice Address - Country:US
Practice Address - Phone:763-559-5522
Practice Address - Fax:763-559-7122
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN2211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39831Medicare UPIN