Provider Demographics
NPI:1295878510
Name:GRIBBLE, JERRY LEON (BA MPH DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEON
Last Name:GRIBBLE
Suffix:
Gender:M
Credentials:BA MPH DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10066 LAKEVIEW CT
Mailing Address - Street 2:WB26A
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-5653
Mailing Address - Country:US
Mailing Address - Phone:254-694-2355
Mailing Address - Fax:
Practice Address - Street 1:10066 LAKEVIEW CT
Practice Address - Street 2:WB26A
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-5653
Practice Address - Country:US
Practice Address - Phone:254-694-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist