Provider Demographics
NPI:1225216377
Name:JESSE A. GRIMM,DDS PA
Entity Type:Organization
Organization Name:JESSE A. GRIMM,DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-996-7770
Mailing Address - Street 1:851 OLD WINSTON ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284
Mailing Address - Country:US
Mailing Address - Phone:336-996-7770
Mailing Address - Fax:
Practice Address - Street 1:851 OLD WINSTON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284
Practice Address - Country:US
Practice Address - Phone:336-996-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental