Healthcare Provider Details

I. General information

NPI: 1629392014
Provider Name (Legal Business Name): ERIC GROVE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57019 YUCCA TRL
YUCCA VALLEY CA
92284-7909
US

IV. Provider business mailing address

72724 29 PALMS HWY
TWENTYNINE PALMS CA
92277-2459
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-0774
  • Fax:
Mailing address:
  • Phone: 760-367-6755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: