=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295853984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM A GRIPPO D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 BEARD RD STE C
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-252-6077
-----------------------------------------------------
Fax | 707-252-7596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3220 BEARD RD STE C
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-252-6077
-----------------------------------------------------
Fax | 707-252-7596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | D23104
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------