Basic Information
| Provider Information | |||||||||
| NPI: | 1295323731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUST FOR GRINS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11876 STAPLETON DR | ||||||||
| Address2: | |||||||||
| City: | FALCON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808318438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193750690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11876 STAPLETON DR | ||||||||
| Address2: | |||||||||
| City: | FALCON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808318438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193750690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | TALBOTT | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | PAMELA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193750690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.