Healthcare Provider Details

I. General information

NPI: 1831237114
Provider Name (Legal Business Name): MARC L GROSSMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 GREEN VALLEY RD
FREEDOM CA
95019-3136
US

IV. Provider business mailing address

228 GREEN VALLEY RD
FREEDOM CA
95019-3136
US

V. Phone/Fax

Practice location:
  • Phone: 831-722-9202
  • Fax: 831-722-4301
Mailing address:
  • Phone: 831-722-9202
  • Fax: 831-722-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number26311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: