Provider Demographics
NPI:1790007714
Name:GRANT, PATRICK C (LD)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:C
Last Name:GRANT
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-5911
Mailing Address - Country:US
Mailing Address - Phone:253-471-9999
Mailing Address - Fax:253-474-2337
Practice Address - Street 1:2902 S 74TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5911
Practice Address - Country:US
Practice Address - Phone:253-471-9999
Practice Address - Fax:253-474-2337
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000196122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5025085Medicaid