Provider Demographics
NPI:1770040735
Name:ROSS, GRANT (DMD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 MAYBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BROCKTON
Mailing Address - State:AL
Mailing Address - Zip Code:36351-5527
Mailing Address - Country:US
Mailing Address - Phone:601-503-3598
Mailing Address - Fax:
Practice Address - Street 1:1100 RUCKER BLVD STE A1
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3623
Practice Address - Country:US
Practice Address - Phone:334-347-5550
Practice Address - Fax:334-347-5551
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24882122300000X
390200000X
ALD.0006775-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program