Healthcare Provider Details

I. General information

NPI: 1205095270
Provider Name (Legal Business Name): EDWARD W GRIMES DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 E 61ST ST
TULSA OK
74136
US

IV. Provider business mailing address

6112 E 61ST ST
TULSA OK
74136
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-9415
  • Fax: 918-492-3377
Mailing address:
  • Phone: 918-492-9415
  • Fax: 918-492-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2748
License Number StateOK

VIII. Authorized Official

Name: DR. EDWARD W GRIMES
Title or Position: OWNER
Credential: DDS
Phone: 918-492-9415