Provider Demographics
NPI:1659934701
Name:GRIMES PEDIATRIC DENTISTRY P C
Entity Type:Organization
Organization Name:GRIMES PEDIATRIC DENTISTRY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-552-0053
Mailing Address - Street 1:40 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-7654
Mailing Address - Country:US
Mailing Address - Phone:563-582-1448
Mailing Address - Fax:563-726-7070
Practice Address - Street 1:1551 SE 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-8861
Practice Address - Country:US
Practice Address - Phone:515-325-1719
Practice Address - Fax:515-373-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty