Healthcare Provider Details

I. General information

NPI: 1164385068
Provider Name (Legal Business Name): BETTY GRULLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 CROSS BRONX EXPY
BRONX NY
10460-4885
US

IV. Provider business mailing address

123 N 7TH AVE
MOUNT VERNON NY
10550-2075
US

V. Phone/Fax

Practice location:
  • Phone: 718-665-7565
  • Fax:
Mailing address:
  • Phone: 347-355-9857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number030908
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: