Healthcare Provider Details

I. General information

NPI: 1609176999
Provider Name (Legal Business Name): GROSSE DMD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W FULLERTON AVE
CHICAGO IL
60647-2243
US

IV. Provider business mailing address

849 N FRANKLIN ST UNIT 1104
CHICAGO IL
60610-8793
US

V. Phone/Fax

Practice location:
  • Phone: 773-235-0000
  • Fax:
Mailing address:
  • Phone: 309-472-0645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019027794
License Number StateIL

VIII. Authorized Official

Name: DR. GINA LEIGH GROSSE
Title or Position: GENERAL DENTIST
Credential: D.M.D.
Phone: 309-472-0645