Provider Demographics
NPI:1346560489
Name:GRILL REPAIR, P.A.
Entity Type:Organization
Organization Name:GRILL REPAIR, P.A.
Other - Org Name:SAGINAW ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELVEBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-897-6006
Mailing Address - Street 1:705 W BAILEY BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 W BAILEY BOSWELL RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1020
Practice Address - Country:US
Practice Address - Phone:817-897-6006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033351408Medicaid