Provider Demographics
NPI:1902814692
Name:GRILLI FAMILY DENTAL CARE LLC
Entity Type:Organization
Organization Name:GRILLI FAMILY DENTAL CARE LLC
Other - Org Name:GARY L GRILLI DDS & GARY F GRILLI DMD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRILLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-644-1509
Mailing Address - Street 1:435 BUCKLAND ROAD
Mailing Address - Street 2:MEDICAL ARTS BUILDING
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-644-1509
Mailing Address - Fax:860-644-1509
Practice Address - Street 1:435 BUCKLAND ROAD
Practice Address - Street 2:MEDICAL ARTS BUILDING
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-644-1509
Practice Address - Fax:860-644-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4251122300000X
CT8941122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty