Provider Demographics
NPI:1003093196
Name:GRIMALDI, BRUCE JEFFREY (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JEFFREY
Last Name:GRIMALDI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2813
Mailing Address - Country:US
Mailing Address - Phone:908-277-0171
Mailing Address - Fax:
Practice Address - Street 1:151 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2813
Practice Address - Country:US
Practice Address - Phone:908-277-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0166691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU30839Medicare UPIN