Healthcare Provider Details

I. General information

NPI: 1235617622
Provider Name (Legal Business Name): DANTE J GRASSO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W. LOCUST ST.
BOONVILLE IN
47601
US

IV. Provider business mailing address

PO BOX 167
BOONVILLE IN
47601-0167
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-3470
  • Fax: 812-897-0068
Mailing address:
  • Phone: 812-897-3470
  • Fax: 812-897-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12013015A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: