Healthcare Provider Details

I. General information

NPI: 1659896827
Provider Name (Legal Business Name): GRANT ROAD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GRANT RD STE 105
MOUNTAIN VIEW CA
94040-3274
US

IV. Provider business mailing address

15075 LOS GATOS BLVD STE 120
LOS GATOS CA
95032-2049
US

V. Phone/Fax

Practice location:
  • Phone: 650-938-8127
  • Fax: 650-230-4925
Mailing address:
  • Phone: 408-884-8155
  • Fax: 408-252-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33512
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ROBERT RUTNER
Title or Position: OWNER
Credential: DDS
Phone: 650-938-8127