Provider Demographics
NPI:1790072510
Name:GRILLO, ZACHARY T (DMD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:T
Last Name:GRILLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 BUCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3708
Mailing Address - Country:US
Mailing Address - Phone:860-648-2848
Mailing Address - Fax:
Practice Address - Street 1:498 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3708
Practice Address - Country:US
Practice Address - Phone:860-648-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0105651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid