Provider Demographics
NPI:1285127951
Name:GRISSOM, AUSTYN C (DMD MSD)
Entity type:Individual
Prefix:
First Name:AUSTYN
Middle Name:C
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27880 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7080
Mailing Address - Country:US
Mailing Address - Phone:251-383-3636
Mailing Address - Fax:251-383-3637
Practice Address - Street 1:27880 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7080
Practice Address - Country:US
Practice Address - Phone:251-383-3636
Practice Address - Fax:251-383-3637
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN274501223E0200X
AL65001223G0001X, 1223E0200X
TX350401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice