Provider Demographics
NPI:1912157405
Name:SMITH, GRANT M (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:M
Last Name:SMITH
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 1:5506 ROYAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4279
Mailing Address - Country:US
Mailing Address - Phone:503-922-9762
Mailing Address - Fax:503-362-8351
Practice Address - Street 1:831 LANCASTER DR NE
Practice Address - Street 2:2
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2676
Practice Address - Country:US
Practice Address - Phone:503-362-8359
Practice Address - Fax:503-362-8351
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist