Provider Demographics
NPI:1134271711
Name:GRILLON, GEORGE LOUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:LOUIS
Last Name:GRILLON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10215 FERNWOOD RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1106
Mailing Address - Country:US
Mailing Address - Phone:301-564-1400
Mailing Address - Fax:301-564-1413
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:SUITE 510
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1106
Practice Address - Country:US
Practice Address - Phone:301-564-1400
Practice Address - Fax:301-564-1413
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD078001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115951800Medicaid
T73521Medicare UPIN
MD104427Medicare UPIN
MD115951800Medicaid