Provider Demographics
NPI:1942291190
Name:GRANT, JEFFREY JOEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOEL
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 1:2202 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2000
Mailing Address - Country:US
Mailing Address - Phone:718-365-6389
Mailing Address - Fax:718-365-6931
Practice Address - Street 1:2202 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2000
Practice Address - Country:US
Practice Address - Phone:718-365-6389
Practice Address - Fax:718-365-6931
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ0288064Medicaid