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General NPI Number Information
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NPI Number | 1225673098
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Entity Type | Organization
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Legal Business Name | 1661 W 2ND CORSICANA PROFESSIONAL, PLLC
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Dates
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Enumeration Date | 11/15/2019
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 1661 W 2ND AVE
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City | CORSICANA
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State | TX
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Zip | 75110-4107
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Country | US
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Telephone | 903-872-1661
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Fax |
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Provider Business Mailing Address
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Address Line | 1661 W 2ND AVE
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City | CORSICANA
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State | TX
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Zip | 75110-4107
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Country | US
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Telephone | 903-872-1661
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PETER GRUMBOS
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Credential | DMD
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Telephone | 214-259-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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