Provider Demographics
NPI:1205095270
Name:EDWARD W GRIMES DDS INC
Entity type:Organization
Organization Name:EDWARD W GRIMES DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-492-9415
Mailing Address - Street 1:6112 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-492-9415
Mailing Address - Fax:918-492-3377
Practice Address - Street 1:6112 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-492-9415
Practice Address - Fax:918-492-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31223E0200X
OK2748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty