Healthcare Provider Details

I. General information

NPI: 1992853204
Provider Name (Legal Business Name): KEITH ROGER GRONBACH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
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:
Title or Position:
Credential:
Phone: