MEDICARE: GRILL REPAIR, P. A.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20522	TX

General Provider Information

NPI Number	:	1750682142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRILL REPAIR, P. A.

Provider Business Mailing Address
First Line	:	PO BOX 161971
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1971
Country	:	US
Telephone Number	:	817-897-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	6225 CHAPEL HILL BLVD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6392
Country	:	US
Telephone Number	:	817-897-6006
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. BRYAN ELVEBAK
Credential	:
Telephone Number	:	940-484-5437

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	11/16/2010

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Directions to “GRILL REPAIR, P. A. ” Practice Location

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