Healthcare Provider Details

I. General information

NPI: 1316422066
Provider Name (Legal Business Name): GROTH DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32100 TELEGRAPH RD STE 195
BINGHAM FARMS MI
48025-2453
US

IV. Provider business mailing address

32100 TELEGRAPH RD STE 195
BINGHAM FARMS MI
48025-2453
US

V. Phone/Fax

Practice location:
  • Phone: 248-885-8247
  • Fax:
Mailing address:
  • Phone: 248-885-8247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KEVIN GROTH
Title or Position: PRESIDENT, OWNER
Credential: DDS
Phone: 248-885-8247