Provider Demographics
NPI:1801924634
Name:GRANT, STEPHEN VANCE (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:VANCE
Last Name:GRANT
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 1:4122 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3242
Mailing Address - Country:US
Mailing Address - Phone:502-896-0133
Mailing Address - Fax:
Practice Address - Street 1:4122 SHELBYVILLE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3242
Practice Address - Country:US
Practice Address - Phone:502-896-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice