Provider Demographics
NPI:1275565889
Name:GRIMSLEY, JOSEPH WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WAYNE
Last Name:GRIMSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N CUTHBERT ST
Mailing Address - Street 2:P.O. BOX 96
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0100311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00353669AMedicare ID - Type UnspecifiedGEORGIA MEDICAID