Provider Demographics
NPI:1801001425
Name:GRILLO, MIGUEL R (DDS,PA)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:R
Last Name:GRILLO
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9136 FOREST HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6564
Mailing Address - Country:US
Mailing Address - Phone:561-784-4670
Mailing Address - Fax:561-791-1390
Practice Address - Street 1:9136 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33411-6564
Practice Address - Country:US
Practice Address - Phone:561-784-4670
Practice Address - Fax:561-791-1390
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN173511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice