Healthcare Provider Details

I. General information

NPI: 1093808594
Provider Name (Legal Business Name): KEITH R. GRONBACH, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3799 MT DIABLO BLVD
LAFAYETTE CA
94549-3538
US

IV. Provider business mailing address

3799 MT DIABLO BLVD
LAFAYETTE CA
94549-3538
US

V. Phone/Fax

Practice location:
  • Phone: 925-283-4050
  • Fax: 925-283-5340
Mailing address:
  • Phone: 925-283-4050
  • Fax: 925-283-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number44317
License Number StateCA

VIII. Authorized Official

Name: DR. KEITH R. GRONBACH
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 925-283-4050