MEDICARE: BETTY GRULLON

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	124Q00000X	Dental Hygienist	030908	NY

General Provider Information

NPI Number	:	1164385068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY GRULLON

Provider Business Mailing Address
First Line	:	979 CROSS BRONX EXPY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10460-4885
Country	:	US
Telephone Number	:	347-355-9857
Fax Number	:

Provider Business Practice Location Address
First Line	:	979 CROSS BRONX EXPY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10460-4885
Country	:	US
Telephone Number	:	718-665-7565
Fax Number	:

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

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	01/06/2026

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