Basic Information
| Provider Information | |||||||||
| NPI: | 1821239872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | JANELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYNES | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | JANELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039522164 | ||||||||
| FaxNumber: | 5035264418 | ||||||||
| Practice Location | |||||||||
| Address1: | 17130 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039522100 | ||||||||
| FaxNumber: | 5036248732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D9316 | OR | Y | Dental Providers | Dentist |
No ID Information.