Healthcare Provider Details

I. General information

NPI: 1558376384
Provider Name (Legal Business Name): CRAIG GRIDER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SW 3RD ST
LEES SUMMIT MO
64063-2326
US

IV. Provider business mailing address

101 SW 3RD ST
LEES SUMMIT MO
64063-2326
US

V. Phone/Fax

Practice location:
  • Phone: 816-246-9995
  • Fax:
Mailing address:
  • Phone: 816-246-9995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE 015889
License Number StateMO

VIII. Authorized Official

Name: DR. CRAIG GRIDER
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 816-246-9995