Healthcare Provider Details

I. General information

NPI: 1578781779
Provider Name (Legal Business Name): KEITH GRIMM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20555 FM 2920 RD
HOCKLEY TX
77447-6910
US

IV. Provider business mailing address

20555 FM 2920 RD
HOCKLEY TX
77447-6910
US

V. Phone/Fax

Practice location:
  • Phone: 281-516-4605
  • Fax: 281-516-4606
Mailing address:
  • Phone: 281-516-4605
  • Fax: 281-516-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20644
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: