Healthcare Provider Details

I. General information

NPI: 1184854283
Provider Name (Legal Business Name): BRAD W GRIFFIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 FM 1960 RD W SUITE B
HOUSTON TX
77069-4519
US

IV. Provider business mailing address

1218 SW MILITARY DR
SAN ANTONIO TX
78221-1535
US

V. Phone/Fax

Practice location:
  • Phone: 281-580-9058
  • Fax:
Mailing address:
  • Phone: 210-928-2814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0024882
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: