Provider Demographics
NPI:1215298567
Name:GRILLIOT, CLARK W (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:W
Last Name:GRILLIOT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4737
Mailing Address - Country:US
Mailing Address - Phone:918-423-0200
Mailing Address - Fax:918-423-6940
Practice Address - Street 1:215 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4737
Practice Address - Country:US
Practice Address - Phone:918-423-0200
Practice Address - Fax:918-423-6940
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK63901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice