Provider Demographics
NPI:1881869055
Name:SW GRANT PC
Entity type:Organization
Organization Name:SW GRANT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-938-3190
Mailing Address - Street 1:2275 S EAGLE RD
Mailing Address - Street 2:STE 140
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5079
Mailing Address - Country:US
Mailing Address - Phone:208-938-3190
Mailing Address - Fax:208-888-1571
Practice Address - Street 1:2275 S EAGLE RD
Practice Address - Street 2:STE 140
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5079
Practice Address - Country:US
Practice Address - Phone:208-938-3190
Practice Address - Fax:208-888-1571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807480600Medicaid
ID6P052OtherBLUE CROSS