Healthcare Provider Details

I. General information

NPI: 1912066366
Provider Name (Legal Business Name): W S GROSSMAN DDS FAMILY LTD PTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 PLYMOUTH AVE
ROCKY RIVER OH
44116-3230
US

IV. Provider business mailing address

2924 PLYMOUTH AVE
ROCKY RIVER OH
44116-3230
US

V. Phone/Fax

Practice location:
  • Phone: 440-333-4987
  • Fax: 440-333-4986
Mailing address:
  • Phone: 440-333-4987
  • Fax: 440-333-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13491
License Number StateOH

VIII. Authorized Official

Name: DR. WALTER S GROSSMAN
Title or Position: GENERAL PARTNER
Credential: DDS
Phone: 440-333-4987