Healthcare Provider Details

I. General information

NPI: 1588809545
Provider Name (Legal Business Name): HEATH A. GROTE, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 CROSSING COURT SUITE C
CHAMPIAGN IL
61822
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 TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number019024132
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number019025871
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. HEATH ALLEN GROTE
Title or Position: OWNER/PRESIDENT
Credential: D.M.D.
Phone: 217-352-5809