Provider Demographics
NPI:1982729372
Name:GRISSOM, JOHN COALSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:COALSON
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 N PARK BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6985
Mailing Address - Country:US
Mailing Address - Phone:817-488-8175
Mailing Address - Fax:817-488-7995
Practice Address - Street 1:210 N PARK BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6985
Practice Address - Country:US
Practice Address - Phone:817-488-8175
Practice Address - Fax:817-488-7995
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice