MEDICARE: DR. JORGE CARLOS GRISWOLD 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	122300000X	Dentist	DN014663	GA

General Provider Information

NPI Number	:	1801225479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE CARLOS GRISWOLD DMD

Provider Business Mailing Address
First Line	:	2680 LAWRENCEVILLE HWY STE 102
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-2526
Country	:	US
Telephone Number	:	678-990-8034
Fax Number	:

Provider Business Practice Location Address
First Line	:	2680 LAWRENCEVILLE HWY STE 102
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-2526
Country	:	US
Telephone Number	:	678-990-8034
Fax Number	:

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	01/17/2016

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