Provider Demographics
NPI:1003095266
Name:GRIMMER, BRYAN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:L
Last Name:GRIMMER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ELDEN ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4868
Mailing Address - Country:US
Mailing Address - Phone:703-478-0315
Mailing Address - Fax:703-478-7451
Practice Address - Street 1:102 ELDEN ST
Practice Address - Street 2:SUITE 17
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4868
Practice Address - Country:US
Practice Address - Phone:703-478-0315
Practice Address - Fax:703-478-7451
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice