Provider Demographics
NPI:1336243948
Name:GRILLI, GARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:GRILLI
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 1:11 ELLRIDGE PLACE
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029
Mailing Address - Country:US
Mailing Address - Phone:860-644-1509
Mailing Address - Fax:860-644-1500
Practice Address - Street 1:435 BUCKLAND RD
Practice Address - Street 2:MEDICAL ARTS BUILDING
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-644-1509
Practice Address - Fax:860-644-1500
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist