=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033473103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITTLEGRINS , P.L.L.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 07/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2179 W 24TH ST STE B
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-4708
-----------------------------------------------------
Fax | 928-782-2212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2179 W 24TH ST STE B
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-4708
-----------------------------------------------------
Fax | 928-782-2212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH DREW GALLEMORE
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 928-782-4708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 4390
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------