Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 8681 | CO |
NPI | 1093999179 |
---|---|
Provider Name | Dr. Brently Allan Grimard |
First Address | Pueblo, CO 81008-1624 |
Second Address | Pueblo, CO 81008-1624 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/12/2007 |
Last Update Date | 02/12/2008 |