Provider Demographics
NPI:1942340104
Name:GRILLO, MIGUEL AGUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:AGUSTIN
Last Name:GRILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12264 EL CAMINO REAL STE 306
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3062
Mailing Address - Country:US
Mailing Address - Phone:858-755-9810
Mailing Address - Fax:858-755-9813
Practice Address - Street 1:12264 EL CAMINO REAL STE 306
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3062
Practice Address - Country:US
Practice Address - Phone:858-755-9810
Practice Address - Fax:858-755-9813
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA414111223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics