Provider Demographics
NPI:1053396853
Name:GRIFFIN, DENISE VESTAL (ORTHOTIC FITTER)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:VESTAL
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:ORTHOTIC FITTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 MAPLEWOOD AVE
Mailing Address - Street 2:STE 116
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4019
Mailing Address - Country:US
Mailing Address - Phone:336-760-2949
Mailing Address - Fax:336-760-0112
Practice Address - Street 1:3010 MAPLEWOOD AVE
Practice Address - Street 2:STE 116
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4019
Practice Address - Country:US
Practice Address - Phone:336-760-2949
Practice Address - Fax:336-760-0112
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7795018Medicaid