Healthcare Provider Details

I. General information

NPI: 1285628776
Provider Name (Legal Business Name): KENNETH W GROMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N BEERS ST SUITE 3
HOLMDEL NJ
07733-1520
US

IV. Provider business mailing address

702 N BEERS ST SUITE 3
HOLMDEL NJ
07733-1520
US

V. Phone/Fax

Practice location:
  • Phone: 732-739-3535
  • Fax: 732-739-1491
Mailing address:
  • Phone: 732-739-3535
  • Fax: 732-739-1491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDI 11661
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: