Provider Demographics
NPI:1093499121
Name:BRIAN M GRISDELA DDS PLLC
Entity Type:Organization
Organization Name:BRIAN M GRISDELA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRISDELA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-449-0005
Mailing Address - Street 1:3854 FOSSUM LN
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2491
Mailing Address - Country:US
Mailing Address - Phone:517-449-0005
Mailing Address - Fax:
Practice Address - Street 1:214 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-9233
Practice Address - Country:US
Practice Address - Phone:517-646-8226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental