Basic Information
Provider Information
NPI: 1861771453
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GRIM
FirstName: GEORGE
MiddleName: JOHN
NamePrefix:  
NameSuffix: JR.
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 425 N DATE ST
Address2:  
City: ESCONDIDO
State: CA
PostalCode: 920253413
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 425 N DATE ST
Address2:  
City: ESCONDIDO
State: CA
PostalCode: 920253413
CountryCode: US
TelephoneNumber: 7605208330
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/12/2011
LastUpdateDate: 08/12/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X18844CAY Dental ProvidersDentistGeneral Practice

No ID Information.


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