Provider Demographics
NPI:1386637239
Name:GRIM, MARK HAIN (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HAIN
Last Name:GRIM
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 1:1259 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6206
Mailing Address - Country:US
Mailing Address - Phone:610-437-1727
Mailing Address - Fax:610-437-4715
Practice Address - Street 1:1259 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6206
Practice Address - Country:US
Practice Address - Phone:610-437-1727
Practice Address - Fax:610-437-4715
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA022456L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT30245Medicare UPIN
PA411955Medicare ID - Type Unspecified