Provider Demographics
NPI:1144720103
Name:GRIN PLLC
Entity type:Organization
Organization Name:GRIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-524-0870
Mailing Address - Street 1:885 PANCHERI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3344
Mailing Address - Country:US
Mailing Address - Phone:208-524-0870
Mailing Address - Fax:208-524-0873
Practice Address - Street 1:2685 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7518
Practice Address - Country:US
Practice Address - Phone:208-522-1164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32031223G0001X
IDD19891223G0001X
IDD37231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000886878OtherUNITED CONCORDIA
001493204OtherUNITED CONCORDIA
ID6K158OtherBLUE CROSS OF IDAHO
ID6C016OtherBLUE CROSS OF IDAHO