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General NPI Number Information
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NPI Number | 1750682142
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Entity Type | Organization
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Legal Business Name | GRILL REPAIR, P. A.
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Dates
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Enumeration Date | 11/16/2010
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Last Update Date | 11/16/2010
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Provider Practice Location Address
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Address Line | 6225 CHAPEL HILL BLVD
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City | PLANO
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State | TX
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Zip | 75093-6392
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Country | US
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Telephone | 817-897-6006
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 161971
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City | FORT WORTH
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State | TX
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Zip | 76161-1971
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Country | US
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Telephone | 817-897-6006
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. BRYAN ELVEBAK
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Credential |
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Telephone | 940-484-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 20522
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License Number State | TX
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