Provider Demographics
NPI:1205028941
Name:JUST FOR GRINS LLC
Entity Type:Organization
Organization Name:JUST FOR GRINS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-392-5111
Mailing Address - Street 1:6436 S US HIGHWAY 85-87
Mailing Address - Street 2:SUITE C
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1005
Mailing Address - Country:US
Mailing Address - Phone:719-392-5111
Mailing Address - Fax:719-392-4143
Practice Address - Street 1:6436 S US HIGHWAY 85-87
Practice Address - Street 2:SUITE C
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817
Practice Address - Country:US
Practice Address - Phone:719-392-5111
Practice Address - Fax:719-392-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31100058Medicaid