Provider Demographics
NPI:1437280922
Name:GREGORY G GRILLO DDS PS
Entity Type:Organization
Organization Name:GREGORY G GRILLO DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-826-4050
Mailing Address - Street 1:PO BOX 1841
Mailing Address - Street 2:739 HAUSSLER RD
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:509-826-0806
Practice Address - Street 1:739 HAUSSLER RD
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9548
Practice Address - Country:US
Practice Address - Phone:509-826-4050
Practice Address - Fax:509-826-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA75261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty