Provider Demographics
NPI:1528702347
Name:GRENNELL, NICHOLAS G (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:GRENNELL
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 1:194 MISSILE AVE
Mailing Address - Street 2:
Mailing Address - City:MINOT AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58705
Mailing Address - Country:US
Mailing Address - Phone:517-449-2272
Mailing Address - Fax:
Practice Address - Street 1:194 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58705
Practice Address - Country:US
Practice Address - Phone:701-723-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016013141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice