Provider Demographics
NPI:1184741829
Name:CHILDRESS-GRUBB, NICKI L (DMD)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:L
Last Name:CHILDRESS-GRUBB
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 RINGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-2215
Mailing Address - Country:US
Mailing Address - Phone:973-831-8950
Mailing Address - Fax:
Practice Address - Street 1:825 RINGWOOD AVE
Practice Address - Street 2:
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-2215
Practice Address - Country:US
Practice Address - Phone:973-831-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ204771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice