Provider Demographics
NPI:1720501380
Name:GRENADER, LION (DMD)
Entity Type:Individual
Prefix:DR
First Name:LION
Middle Name:
Last Name:GRENADER
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 1:400 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:644 SHERIDAN RD # D
Practice Address - Street 2:
Practice Address - City:WINTHROP HARBOR
Practice Address - State:IL
Practice Address - Zip Code:60096-1350
Practice Address - Country:US
Practice Address - Phone:847-872-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist