Healthcare Provider Details

I. General information

NPI: 1902966898
Provider Name (Legal Business Name): DANIEL J GROB DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25225 N LAKE PLEASANT PKWY STE 1240
PEORIA AZ
85383-1390
US

IV. Provider business mailing address

150 N PANTANO RD SUITE 100
TUCSON AZ
85710
US

V. Phone/Fax

Practice location:
  • Phone: 623-572-2683
  • Fax:
Mailing address:
  • Phone: 520-290-8787
  • Fax: 520-290-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3317
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3317
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: