Provider Demographics
NPI:1821662297
Name:ROGER GLEN GRIMBALL JR. D.D.S. LLC
Entity Type:Organization
Organization Name:ROGER GLEN GRIMBALL JR. D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:GRIMBALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:337-625-2212
Mailing Address - Street 1:1570 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5643
Mailing Address - Country:US
Mailing Address - Phone:337-625-2212
Mailing Address - Fax:331-625-3231
Practice Address - Street 1:1570 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5643
Practice Address - Country:US
Practice Address - Phone:337-625-2212
Practice Address - Fax:337-625-3231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty