Provider Demographics
NPI:1821209776
Name:LOOSVELT, GRANT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:A
Last Name:LOOSVELT
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 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-277-5678
Mailing Address - Fax:310-277-3294
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1601
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-277-5678
Practice Address - Fax:310-277-3294
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist