Provider Demographics
NPI:1922339050
Name:GRANT, MARK CULLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CULLEN
Last Name:GRANT
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 1:4613 W OREM DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77045-4107
Mailing Address - Country:US
Mailing Address - Phone:713-433-4333
Mailing Address - Fax:
Practice Address - Street 1:4613 W OREM DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77045-4107
Practice Address - Country:US
Practice Address - Phone:713-433-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00251911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice