Provider Demographics
NPI:1629811278
Name:GRILLIOT, SCOTT CHARLES (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHARLES
Last Name:GRILLIOT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E VENTURE WAY APT 3104
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1203
Mailing Address - Country:US
Mailing Address - Phone:309-830-5306
Mailing Address - Fax:208-282-1040
Practice Address - Street 1:921 S 8TH AVE STOP 8088
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-4008
Practice Address - Country:US
Practice Address - Phone:208-282-1040
Practice Address - Fax:208-282-1040
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist