MEDICARE: KEITH GRIMM DMD

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	20644	TX

General Provider Information

NPI Number	:	1578781779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH GRIMM DMD

Provider Business Mailing Address
First Line	:	20555 FM 2920 RD
Second Line	:
City	:	HOCKLEY
State	:	TX
Zip	:	77447-6910
Country	:	US
Telephone Number	:	281-516-4605
Fax Number	:	281-516-4606

Provider Business Practice Location Address
First Line	:	20555 FM 2920 RD
Second Line	:
City	:	HOCKLEY
State	:	TX
Zip	:	77447-6910
Country	:	US
Telephone Number	:	281-516-4605
Fax Number	:	281-516-4606

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/19/2012

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