Provider Demographics
NPI:1649889270
Name:GRULLON, VANESA MELINA (DMD)
Entity type:Individual
Prefix:DR
First Name:VANESA
Middle Name:MELINA
Last Name:GRULLON
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 1:6559 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7661
Mailing Address - Country:US
Mailing Address - Phone:561-574-5504
Mailing Address - Fax:
Practice Address - Street 1:600 S DIXIE HWY # 105A
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-5824
Practice Address - Country:US
Practice Address - Phone:561-820-8898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist