Provider Demographics
NPI:1982680377
Name:GRIMM, THOMAS J (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:GRIMM
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 1:149 HART STREET
Mailing Address - Street 2:82 MEDICAL GROUP/CREDENTIALS
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-3482
Mailing Address - Country:US
Mailing Address - Phone:940-676-6569
Mailing Address - Fax:
Practice Address - Street 1:149 HART STREET
Practice Address - Street 2:82 MEDICAL GROUP/CREDENTIALS
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3482
Practice Address - Country:US
Practice Address - Phone:940-676-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN