Healthcare Provider Details

I. General information

NPI: 1669929519
Provider Name (Legal Business Name): TERRY GRUELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 N GRAND AVE SUITE 301
FORT THOMAS KY
41075-4107
US

IV. Provider business mailing address

40 N GRAND AVE SUITE 301
FORT THOMAS KY
41075-4107
US

V. Phone/Fax

Practice location:
  • Phone: 859-441-2369
  • Fax: 859-442-3222
Mailing address:
  • Phone: 859-441-2369
  • Fax: 859-442-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: