Healthcare Provider Details

I. General information

NPI: 1760863591
Provider Name (Legal Business Name): KATHERINE CALVERT GROSSO D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

IV. Provider business mailing address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-8747
  • Fax:
Mailing address:
  • Phone: 860-677-8747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12724
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: