Provider Demographics
NPI:1821398223
Name:GRIDLEY, JESSE R (DMD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:GRIDLEY
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 1:1885 WAITE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1210
Mailing Address - Country:US
Mailing Address - Phone:541-756-1117
Mailing Address - Fax:541-756-3811
Practice Address - Street 1:1885 WAITE ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1210
Practice Address - Country:US
Practice Address - Phone:541-756-1117
Practice Address - Fax:541-756-3811
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD94661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice