Provider Demographics
NPI:1174537989
Name:GRIDER, DONALD LEON (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:LEON
Last Name:GRIDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 9TH ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2895
Mailing Address - Country:US
Mailing Address - Phone:706-327-9936
Mailing Address - Fax:
Practice Address - Street 1:424 9TH ST
Practice Address - Street 2:SUITE #1
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2895
Practice Address - Country:US
Practice Address - Phone:706-327-9936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000966908BMedicaid
GA000966908EMedicaid