Provider Demographics
NPI:1912526203
Name:421 N 38TH KILLEEN PROFESSIONAL, PLLC
Entity Type:Organization
Organization Name:421 N 38TH KILLEEN PROFESSIONAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:214-259-7000
Mailing Address - Street 1:421 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4153
Mailing Address - Country:US
Mailing Address - Phone:254-634-0234
Mailing Address - Fax:
Practice Address - Street 1:421 N 38TH ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-4153
Practice Address - Country:US
Practice Address - Phone:254-634-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty