Provider Demographics
NPI:1174739452
Name:RODKEY, GRANT F (DMD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:F
Last Name:RODKEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:EASTERN STATE HOSPITAL
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-4705
Practice Address - Street 1:850 MAPLE STREET
Practice Address - Street 2:EASTERN STATE HOSPITAL
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-4705
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000081981223G0001X
IDD33371223G0001X
ORD74341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice