Provider Demographics
NPI:1205981842
Name:GRIZZLE, EDNA S (DMD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:S
Last Name:GRIZZLE
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 1:490 ALABAMA ST.
Mailing Address - Street 2:#105
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:909-335-0500
Mailing Address - Fax:909-335-0502
Practice Address - Street 1:490 ALABAMA ST.
Practice Address - Street 2:#105
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-335-0500
Practice Address - Fax:909-335-0501
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice