Healthcare Provider Details

I. General information

NPI: 1235184482
Provider Name (Legal Business Name): HEATH A GROTE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 CROSSING CT SUITE C
CHAMPAIGN IL
61822-6199
US

IV. Provider business mailing address

2916 CROSSING COURT SUITE C
CHAMPAIGN IL
61822
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-5809
  • Fax: 217-352-5812
Mailing address:
  • Phone: 217-352-5809
  • Fax: 217-352-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number019024132
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: