Provider Demographics
NPI:1831490226
Name:GRILL REPAIR, P.A.
Entity Type:Organization
Organization Name:GRILL REPAIR, P.A.
Other - Org Name:ORTHODONTICS AT THE DENTAL AND IMPLANT SUITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELVEBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-571-2100
Mailing Address - Street 1:458 MID CITIES BLVD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2430
Mailing Address - Country:US
Mailing Address - Phone:817-571-2100
Mailing Address - Fax:
Practice Address - Street 1:458 MID CITIES BLVD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2430
Practice Address - Country:US
Practice Address - Phone:817-571-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty