Provider Demographics
NPI:1225673098
Name:1661 W 2ND CORSICANA PROFESSIONAL, PLLC
Entity Type:Organization
Organization Name:1661 W 2ND CORSICANA PROFESSIONAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:214-259-7000
Mailing Address - Street 1:1661 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4107
Mailing Address - Country:US
Mailing Address - Phone:903-872-1661
Mailing Address - Fax:
Practice Address - Street 1:1661 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4107
Practice Address - Country:US
Practice Address - Phone:903-872-1661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-15
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty