Provider Demographics
NPI:1114012200
Name:GRIMES-MOORE, FREIDA CAROLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREIDA
Middle Name:CAROLE
Last Name:GRIMES-MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MERRILL LEAF CT.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:901-864-1990
Mailing Address - Fax:
Practice Address - Street 1:2941 TWO NOTCH ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-251-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8796Medicaid