Provider Demographics
NPI:1891411658
Name:GRISSOM ENDODONTICS AND MICROSURGERY, PLLC
Entity Type:Organization
Organization Name:GRISSOM ENDODONTICS AND MICROSURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTYN
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:GRISSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:251-383-3636
Mailing Address - Street 1:27880 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7080
Mailing Address - Country:US
Mailing Address - Phone:251-383-3636
Mailing Address - Fax:251-383-3637
Practice Address - Street 1:27880 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7080
Practice Address - Country:US
Practice Address - Phone:251-383-3636
Practice Address - Fax:251-383-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty