Healthcare Provider Details

I. General information

NPI: 1942340104
Provider Name (Legal Business Name): MIGUEL AGUSTIN GRILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL STE 306
SAN DIEGO CA
92130-3062
US

IV. Provider business mailing address

12264 EL CAMINO REAL STE 306
SAN DIEGO CA
92130-3062
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-9810
  • Fax: 858-755-9813
Mailing address:
  • Phone: 858-755-9810
  • Fax: 858-755-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number41411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: