Provider Demographics
NPI:1073297909
Name:GRISHIN, VLADIMIR A (DDS)
Entity Type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:A
Last Name:GRISHIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:VLADIMIR
Other - Middle Name:
Other - Last Name:GRISHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2105 W KEARNEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2105 W KEARNEY ST STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1666
Practice Address - Country:US
Practice Address - Phone:417-862-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist