Provider Demographics
NPI:1265681092
Name:GRIMSLEY DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:GRIMSLEY DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRIMSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-758-3345
Mailing Address - Street 1:115 N CUTHBERT ST
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-3401
Mailing Address - Country:US
Mailing Address - Phone:229-758-3345
Mailing Address - Fax:229-758-3339
Practice Address - Street 1:115 N CUTHBERT ST
Practice Address - Street 2:
Practice Address - City:COLQUITT
Practice Address - State:GA
Practice Address - Zip Code:39837-3401
Practice Address - Country:US
Practice Address - Phone:229-758-3345
Practice Address - Fax:229-758-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013335261QD0000X
GADN010031261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300014425AMedicaid