Provider Demographics
NPI:1598475949
Name:PETER GRUMBOS DDS RANDOLPH PLLC
Entity Type:Organization
Organization Name:PETER GRUMBOS DDS RANDOLPH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-292-1349
Mailing Address - Street 1:12200 W FINCH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-7427
Mailing Address - Country:US
Mailing Address - Phone:252-292-1349
Mailing Address - Fax:919-278-2657
Practice Address - Street 1:2711 RANDOLPH RD STE 205
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2027
Practice Address - Country:US
Practice Address - Phone:704-377-2503
Practice Address - Fax:704-377-6032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty