Provider Demographics
NPI:1801225479
Name:GRISWOLD, JORGE CARLOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORGE CARLOS
Middle Name:
Last Name:GRISWOLD
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 1:2680 LAWRENCEVILLE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2526
Mailing Address - Country:US
Mailing Address - Phone:678-990-8034
Mailing Address - Fax:
Practice Address - Street 1:2680 LAWRENCEVILLE HWY STE 102
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2526
Practice Address - Country:US
Practice Address - Phone:678-990-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2016-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014663122300000X
IL019029575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist