Provider Demographics
NPI:1750044699
Name:GRILLZ
Entity Type:Organization
Organization Name:GRILLZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEININGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-936-9244
Mailing Address - Street 1:4513 ENTERPRISE WAY
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605
Mailing Address - Country:US
Mailing Address - Phone:208-936-9244
Mailing Address - Fax:
Practice Address - Street 1:4513 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-936-9244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental