Provider Demographics
NPI:1306837158
Name:GRIMES, MICHAEL LILLIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LILLIS
Last Name:GRIMES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2550 MOSSIDE BLVD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3540
Mailing Address - Country:US
Mailing Address - Phone:412-856-8002
Mailing Address - Fax:
Practice Address - Street 1:2550 MOSSIDE BLVD
Practice Address - Street 2:SUITE 213
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3540
Practice Address - Country:US
Practice Address - Phone:412-856-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-019035-L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry