Healthcare Provider Details

I. General information

NPI: 1285127951
Provider Name (Legal Business Name): AUSTYN C GRISSOM DMD MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7133 STONE DR
DAPHNE AL
36526-4825
US

IV. Provider business mailing address

703 OLIVE AVE
FAIRHOPE AL
36532-2805
US

V. Phone/Fax

Practice location:
  • Phone: 251-383-3636
  • Fax: 251-383-3637
Mailing address:
  • Phone: 251-383-3636
  • Fax: 251-383-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN27450
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6500
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6500
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: