Provider Demographics
NPI:1144955790
Name:SEVERS, GRANT (DMD MS)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:SEVERS
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3915 MAINE ST STE 2
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5843
Practice Address - Country:US
Practice Address - Phone:217-919-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0031571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty