Healthcare Provider Details

I. General information

NPI: 1942750559
Provider Name (Legal Business Name): TSO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 N GRAND AVE SUITE 301
FORT THOMAS KY
41075-4107
US

IV. Provider business mailing address

40 N GRAND AVE SUITE 301
FORT THOMAS KY
41075-4107
US

V. Phone/Fax

Practice location:
  • Phone: 859-441-2369
  • Fax: 859-442-3222
Mailing address:
  • Phone: 859-441-2369
  • Fax: 859-442-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8737
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4118
License Number StateKY

VIII. Authorized Official

Name: TERRY GRUELLE
Title or Position: OWNER
Credential:
Phone: 859-441-2369