Provider Demographics
NPI:1164734976
Name:GRITTNER, JOHN R
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GRITTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MAILSTOP 21113A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425
Mailing Address - Country:US
Mailing Address - Phone:952-883-5155
Mailing Address - Fax:952-883-5160
Practice Address - Street 1:205 S WABASHA ST
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1805
Practice Address - Country:US
Practice Address - Phone:651-293-8300
Practice Address - Fax:651-293-8130
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist