Provider Demographics
NPI:1578671103
Name:GRANT-HYMAN, KENISHA LASHAE (DDS)
Entity type:Individual
Prefix:
First Name:KENISHA
Middle Name:LASHAE
Last Name:GRANT-HYMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-9357
Mailing Address - Country:US
Mailing Address - Phone:919-562-1520
Mailing Address - Fax:919-562-3296
Practice Address - Street 1:6250 ROGERS RD
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9357
Practice Address - Country:US
Practice Address - Phone:919-562-1520
Practice Address - Fax:919-562-3296
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9021MOtherBLUE CROSS BLUE SHIELD NC
NC5901040Medicaid