Provider Demographics
NPI:1144886565
Name:GLEASON, GRANT JOSEPH (DMD)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:JOSEPH
Last Name:GLEASON
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 1:320 W 38TH ST APT 1725
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-5254
Mailing Address - Country:US
Mailing Address - Phone:617-669-9945
Mailing Address - Fax:
Practice Address - Street 1:3905 61ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3566
Practice Address - Country:US
Practice Address - Phone:718-577-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY061646-01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program