Provider Demographics
NPI:1396479234
Name:PETER GRUMBOS DDS NORTHWAY PLLC
Entity type:Organization
Organization Name:PETER GRUMBOS DDS NORTHWAY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-722-4422
Mailing Address - Street 1:120 NORTHWAY CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4916
Mailing Address - Country:US
Mailing Address - Phone:919-847-6000
Mailing Address - Fax:919-847-3159
Practice Address - Street 1:120 NORTHWAY CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4916
Practice Address - Country:US
Practice Address - Phone:919-847-6000
Practice Address - Fax:919-847-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty