Provider Demographics
NPI:1881832509
Name:CRANIO MANDIBULAR AFFILIATES
Entity Type:Organization
Organization Name:CRANIO MANDIBULAR AFFILIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:432-522-3546
Mailing Address - Street 1:4214 ANDREWS HWY
Mailing Address - Street 2:STE-307
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4822
Mailing Address - Country:US
Mailing Address - Phone:432-522-3546
Mailing Address - Fax:432-522-1882
Practice Address - Street 1:4214 ANDREWS HWY
Practice Address - Street 2:STE-307
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4822
Practice Address - Country:US
Practice Address - Phone:432-522-3546
Practice Address - Fax:432-522-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083621692OtherNONE