Provider Demographics
NPI:1699117051
Name:GRIDER, DENNIS WAYNE
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:WAYNE
Last Name:GRIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52087 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-4540
Mailing Address - Country:US
Mailing Address - Phone:586-838-8520
Mailing Address - Fax:
Practice Address - Street 1:6905 ROCHESTER RD
Practice Address - Street 2:SUITE C
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1282
Practice Address - Country:US
Practice Address - Phone:248-828-1100
Practice Address - Fax:248-828-1101
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001939225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant