Healthcare Provider Details

I. General information

NPI: 1821260951
Provider Name (Legal Business Name): MICHAEL H GROUSD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W IRVINGTON RD STE 180
TUCSON AZ
85746-4102
US

IV. Provider business mailing address

PO BOX 1450
TUBAC AZ
85646-1450
US

V. Phone/Fax

Practice location:
  • Phone: 520-777-1428
  • Fax:
Mailing address:
  • Phone: 520-310-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDO7926
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: