Provider Demographics
NPI:1093999179
Name:GRIMARD, BRENTLY ALLAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRENTLY
Middle Name:ALLAN
Last Name:GRIMARD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 OUTLOOK BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1624
Mailing Address - Country:US
Mailing Address - Phone:719-545-6485
Mailing Address - Fax:719-545-6486
Practice Address - Street 1:3903 OUTLOOK BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1624
Practice Address - Country:US
Practice Address - Phone:719-545-6485
Practice Address - Fax:719-545-6486
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86811223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics