Provider Demographics
NPI:1346578739
Name:GRILLO, GREGORY GERALD (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:GERALD
Last Name:GRILLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1841
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-1841
Mailing Address - Country:US
Mailing Address - Phone:509-826-4050
Mailing Address - Fax:509-826-9436
Practice Address - Street 1:739 HAUSSLER RD
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9547
Practice Address - Country:US
Practice Address - Phone:509-826-5040
Practice Address - Fax:509-826-9436
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist