Provider Demographics
NPI:1386623171
Name:GRISHAM, MILTON JOSEPH JR (DO)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:JOSEPH
Last Name:GRISHAM
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11823 MERIDEN LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4335
Mailing Address - Country:US
Mailing Address - Phone:858-208-8351
Mailing Address - Fax:
Practice Address - Street 1:2841 RENDOVA ROAD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5490
Practice Address - Country:US
Practice Address - Phone:619-437-2117
Practice Address - Fax:619-437-2700
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist