Provider Demographics
NPI:1720197809
Name:GRIPPE, ROBERT BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRIAN
Last Name:GRIPPE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:
Other - Last Name:GRIPPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 2249
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-2249
Mailing Address - Country:US
Mailing Address - Phone:270-866-7222
Mailing Address - Fax:
Practice Address - Street 1:458 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-866-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7471122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000007Medicaid
KY45002474Medicaid