Provider Demographics
NPI:1255401899
Name:GRINTER, JASON MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:GRINTER
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 1:4316 N CLARENDON AVE
Mailing Address - Street 2:#1611
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1562
Mailing Address - Country:US
Mailing Address - Phone:773-369-5428
Mailing Address - Fax:
Practice Address - Street 1:275 N PHELPS AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2434
Practice Address - Country:US
Practice Address - Phone:815-484-8678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist