Provider Demographics
NPI:1740648179
Name:HEALTHY GRILLZ DENTAL HYGIENE PBC
Entity type:Organization
Organization Name:HEALTHY GRILLZ DENTAL HYGIENE PBC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:720-496-6422
Mailing Address - Street 1:12391 E CORNELL AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3323
Mailing Address - Country:US
Mailing Address - Phone:720-496-6422
Mailing Address - Fax:
Practice Address - Street 1:12391 E CORNELL AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3323
Practice Address - Country:US
Practice Address - Phone:720-496-6422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-30
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000905643124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56588551Medicaid