MEDICARE: DR. LOUIS MICHAEL GRILLON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	15603	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15603	OTHER	MA	DENTAL LICENSE #

General Provider Information

NPI Number	:	1063497170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOUIS MICHAEL GRILLON D.D.S.

Provider Business Mailing Address
First Line	:	436 CHICOPEE ST
Second Line	:
City	:	CHICOPEE
State	:	MA
Zip	:	01013-1941
Country	:	US
Telephone Number	:	413-533-0528
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 CHICOPEE ST
Second Line	:
City	:	CHICOPEE
State	:	MA
Zip	:	01013-1941
Country	:	US
Telephone Number	:	413-533-0528
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	07/08/2007

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