Healthcare Provider Details

I. General information

NPI: 1215662788
Provider Name (Legal Business Name): CODY SHAWN GROLL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

PO BOX 1808
PITTSBURG KS
66762-1808
US

V. Phone/Fax

Practice location:
  • Phone: 202-319-8736
  • Fax: 620-231-5062
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12891810-9922
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61967
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: