=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558376384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRAIG GRIDER DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 04/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SW 3RD ST
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64063-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-246-9995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 SW 3RD ST
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64063-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-246-9995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CRAIG GRIDER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 816-246-9995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DE 015889
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------