Provider Demographics
NPI:1780990168
Name:RUTHERFORD, GRANT RUSSELL (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:RUSSELL
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 MOANA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3910
Mailing Address - Country:US
Mailing Address - Phone:303-513-1361
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL CAMP PENDLETON
Practice Address - Street 2:200 MERCY CIRCLE
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-763-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10238122300000X
CA1088271223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist