Provider Demographics
NPI:1003830597
Name:GRIMBALL, ROGER GLEN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GLEN
Last Name:GRIMBALL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:910 BEGLIS PKWY
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5102
Mailing Address - Country:US
Mailing Address - Phone:337-625-2212
Mailing Address - Fax:337-625-3231
Practice Address - Street 1:910 BEGLIS PKWY
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5102
Practice Address - Country:US
Practice Address - Phone:337-625-2212
Practice Address - Fax:337-625-3231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA53301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1853305Medicaid