Provider Demographics
NPI:1821641614
Name:GRANT, NICOLE REYES (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:REYES
Last Name:GRANT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:MALDIA
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1830 E BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1830 E BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9161
Practice Address - Country:US
Practice Address - Phone:817-477-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX355101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice