Provider Demographics
NPI:1649264565
Name:GRILL, MATT TAVIS (DDS)
Entity type:Individual
Prefix:DR
First Name:MATT
Middle Name:TAVIS
Last Name:GRILL
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 1:436 E OGLETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-3805
Mailing Address - Country:US
Mailing Address - Phone:843-290-0573
Mailing Address - Fax:
Practice Address - Street 1:207 E 31ST ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-7304
Practice Address - Country:US
Practice Address - Phone:912-232-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice