Provider Demographics
NPI:1053317255
Name:GRIMES, GARY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:GRIMES
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 1:4715 TAFT BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5001
Mailing Address - Country:US
Mailing Address - Phone:940-692-8821
Mailing Address - Fax:940-692-9475
Practice Address - Street 1:4715 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-5001
Practice Address - Country:US
Practice Address - Phone:940-692-8821
Practice Address - Fax:940-692-9475
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist