Healthcare Provider Details

I. General information

NPI: 1831163310
Provider Name (Legal Business Name): BEVERLY ANNETTE GRINSLADE HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 GARRISON AVE
PORT ST JOE FL
32456-5265
US

IV. Provider business mailing address

700 TRANSMITTER RD
PANAMA CITY FL
32401-5394
US

V. Phone/Fax

Practice location:
  • Phone: 850-227-1276
  • Fax:
Mailing address:
  • Phone: 850-784-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH12070
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: