Healthcare Provider Details

I. General information

NPI: 1487343570
Provider Name (Legal Business Name): CAL GRUTZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S OSAGE AVE
TIPTON MO
65081-8470
US

IV. Provider business mailing address

1127 ROCK CUT RD
HAZEL GREEN WI
53811-9719
US

V. Phone/Fax

Practice location:
  • Phone: 563-513-9612
  • Fax:
Mailing address:
  • Phone: 563-513-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2023024441
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: