Healthcare Provider Details

I. General information

NPI: 1639005713
Provider Name (Legal Business Name): GRACIE ANN GROTH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 LAKEWOOD RANCH BLVD
BRADENTON FL
34211-4953
US

IV. Provider business mailing address

11007 VIDA CIR UNIT 207
BRADENTON FL
34211-2289
US

V. Phone/Fax

Practice location:
  • Phone: 941-405-1600
  • Fax:
Mailing address:
  • Phone: 608-790-1622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN31936
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: