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General NPI Number Information
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NPI Number | 1821662297
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Entity Type | Organization
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Legal Business Name | ROGER GLEN GRIMBALL JR. D.D.S. LLC
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Dates
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Enumeration Date | 05/19/2021
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Last Update Date | 07/28/2021
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Provider Practice Location Address
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Address Line | 1570 MAPLEWOOD DR
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City | SULPHUR
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State | LA
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Zip | 70663-5643
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Country | US
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Telephone | 337-625-2212
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Fax | 337-625-3231
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Provider Business Mailing Address
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Address Line | 1570 MAPLEWOOD DR
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City | SULPHUR
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State | LA
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Zip | 70663-5643
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Country | US
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Telephone | 337-625-2212
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Fax | 331-625-3231
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ROGER GLEN GRIMBALL JR.
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Credential |
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Telephone | 337-625-2212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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