Provider Demographics
NPI:1922017847
Name:GRIFFIN, JERRY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 MEADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-4317
Mailing Address - Country:US
Mailing Address - Phone:325-698-8595
Mailing Address - Fax:
Practice Address - Street 1:2501 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-5058
Practice Address - Country:US
Practice Address - Phone:325-795-3298
Practice Address - Fax:325-795-3203
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX97871223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84C113OtherBCBS PROVIDER #
TX84C113OtherBCBS PROVIDER #