Provider Demographics
NPI:1023348729
Name:GRIMSLID, HOLLY J (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:J
Last Name:GRIMSLID
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4102
Mailing Address - Country:US
Mailing Address - Phone:608-782-6778
Mailing Address - Fax:
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4102
Practice Address - Country:US
Practice Address - Phone:608-782-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5251-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics